It’s Not Too Late to Change your Medicare Advantage plan

Since 2019, subscribers of Medicare Advantage (MA) plans have three additional months (January-March each year) to change their plan. 

Why would you want to change your MA plans now?

Some reasons could include:

  •  You missed the Annual Fall Open Enrollment period (October 15-December 7)
  • You didn’t realize your MA plan doesn’t include your medications, preferred doctors, hospitals, pharmacies, etc.
  • Your health condition has changed and you want better/different coverage.
  • Your financial situation has changed and you can’t afford your current MA plan.
  • You or your relative didn’t understand the limitations, cost, or consequences of their current plan.
  • You got bad advice from a former friend or salesman.

Normally, you wouldn’t be able to change plans for these reasons during the calendar year, except in special circumstances (eg. moved out of service area, plan termination, end of employer coverage etc.). However, now you have 3 additional months to make a change each year.

To be eligible to make a change, you must currently be a subscriber of a Medicare Advantage plan (as opposed to being a subscriber to Original Medicare).

What are Some Permitted Changes?

  • You can change from one MA plan to another (either with the same or a different insurer)
  • You can select a new MA plan that either increases or decreases your coverage and/or cost.
  • You can terminate your MA plan and switch to Original Medicare and buy (or not buy), a stand-alone Prescription Drug Plan (PDP).
  • In some states, like New York, you can also choose to purchase a Medicare Supplemental (Medigap) plan for added coverage to Original Medicare, with or without purchasing a PDP.

How to Change Your Medicare Advantage Plan?

  • If you want to explore other MA plan options with your existing MA insurance company, call their member services dept. (a phone number is listed on the back of your insurance card).
  • If you purchased your plan through an insurance broker that you feel provides great service, call them.
  • If you know one or more specific insurance companies and of their MA plans that you are considering you can call them or enroll in a specific on their website or on Medicare.gov. However, a company salesperson is only representing and getting paid by their company, so don’t expect them to recommend their competitors.)
  • If you want to compare options among different MA insurers in your service area, go to Medicare.gov and select “plan finder” and enter your information and select different insurance companies and their plans to compare.

Are there independent people who can help you review your options, their coverage & limitations and costs?

Yes, there are a number of free, independent people that don’t work for insurance companies or receive any sales commissions that can help you understand these complex issues.  They include:

 
Use the site below to find local representatives in your community.

SHIP connects you with local individual and group information/assistance in your community regarding Medicare issues and questions.

https://www.medicarerights.org

Medicare Rights Center: 800-333-4114

MRC is a national non-profit agency that helps people with Medicare understand their rights, benefits and helps them navigate the complex Medicare system. 

Caution

Please be cautious of responding to the endless TV ads with 60’s Jets quarterback Joe Namath (The Medicare Helpline), door-to-door salespeople, group insurance presentations, emails, and USPS junk mail advertising to help “get you the free benefits that you are entitled to”. These are deceptive ads aimed at getting your contact info, selling it to a commissioned salesperson, who will follow-up and personally try to sell you plans that pay them. 

 

Updated 12/29/20

Help is Available for Seniors Struggling to Live Independently

The National Council on Aging (NCOA), is a tax-exempt non-profit organization that helps older adults and their caregivers, meet the challenges of aging, often on a fixed income, through services like BenefitsCheckUp®.

BenefitsCheckUp is a free online service that connects older adults with information on a variety of benefits they may need and qualify for including, assistance with the cost of housing & utilities, food, health care, and insurance, medications, Veteran benefits, transportation, and more.

For more info, call 1-800-794-6559 or go to https://www.ncoa.org

Do you have Diabetes, use Insulin, and are on Medicare?

If the answer is yes, and you’re paying more than $35 a month for insulin, keep reading….

In 2021, Medicare introduced a pilot program called the Senior Saving Model  (SSM) with the aim of reducing the cost of insulin to people on Medicare and improving the quality of their health care.

Who is eligible for this discounted insulin program?

  • People that have diabetes and are prescribed insulin
  • People that are enrolled in Medicare Advantage (MA-PD) plans or Medicare Prescription Drug Plans (PDP) that agreed to participates in the SSM.
  • People that take insulin from manufacturers that participates in the SSM.

What insurance companies and plans participate in the SSM?

There are a variety of insurance companies that sell Medicare Advantage (MA-PD) and stand-alone Prescription Drug Plans (PDP) ranging from large for-profits such as United HealthCare, Humana & CVS to regional non-profits such as BCBS affiliates to small plans with limited subscribers.

To illustrate, in Rochester, NY with a metropolitan population of over 1 million, there are 22 Medicare Advantage plans offered by 5 major insurers: Excellus (BCBS), MVP, CVS/Aetna, United HealthCare, and Wellcare. These insurers sell 22 different MA plans, however, only 4 plans from Excellus and 4 plans United HealthCare participates in the $35/mo. insulin SSM program.

In addition, there are 19 prescription drug plans (PDP) offered in Rochester to individuals that choose to enroll in either Original Medicare or a Medigap plan. Not all PDP insurers participate in the SSM program and not all of their plans include the $35/mo. insulin.

Some insurers offer discounted insulin in their plans with higher monthly premiums. So, you need to carefully evaluate the total cost of each plan including the premium, deductibles, and the price of your prescriptions, with and without the discounted insulin. A plan with discounted insulin may not be the lowest total cost plan when you include the total costs of the plan and all of your medications.

What Insulin brands participate in the SSM program?

Insurers that participate in the SSM program are required to include at least one vial and one pen dosage form for each of the different types of Model insulins, where available and including – rapid acting, short-acting, intermediate-acting and long-acting – all for at a maximum $35 copay for a one-month supply.

Participating Insulin Manufacturers include:

  1. Eli Lilly and Company
  2. MannKind Corporation
  3. Mylan Specialty L.P.
  4. Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
  5. Sanofi-Aventis U.S. LLC

How can you find out if your current plan or other plans available to you, participates in the $35/mo. SSM program and what specific insulins are included?

  • Call your plan’s member services (number is listed on the back of your card)
  • Ask your pharmacist
  • Call & ask Medicare at 800-633-4227
  • Check online at Medicare.gov/plan-compare. 

With the online http://www.medicare.gov/plan-compare, after you input all your medications, you will see an estimate of your total annual out-of-pocket expenses for each plan that you are considering, and for each of your medications and the pharmacy that you select.

Please keep in mind, the Medicare Open Enrollment period end on December 7th, for changes in MA-PD and PDPs that will become effective January 1,2022.

Best wishes

Making the Most of your Health Insurance Benefits before Year-End 

As we enter the end of the year, it’s important to check if your health insurance plan has benefits that you need, but have not used and will be erased on New Year’s eve.

This applies to Medicare Advantage (MA) plans as well as some employer and marketplace plans.

Some plan benefits that you may have, but could use or lose, before year-end include:

  • Prescription drugs, preferred pharmacies and mail-order
  • Vaccines
  • Preventative dental care
  • Contact lens/eyewear allowances
  • Healthy living rewards
  • Over-the-counter medication/supplies
  • Telehealth consults

Prescription Medications

The cost of prescription medications can be your highest medical expense each year and its one of the most complicated and least disclosed aspect of your health insurance. There can be considerable differences among private Medicare Advantage plan insurers in their cost, choice & access to the medications that your doctor prescribes. 

To help understand these differences, go to Medicare Plan Finder and enter your medications for Medicare Advantage plans in your area and the program will show the comparative: medical and drug premiums, deductibles, co-pays and co-insurance and optional benefits for all plans. Then, you can select a more detailed comparison of up to 3 plans that you are most interested in buying for 2022, before December 7th.

A couple things of other things that you can do before year-end is to check if your current plan offers discounts for using: 1. a preferred pharmacy 2. a discount for 90-day supplies of your maintenance meds (usually generics) from your plan’s preferred mail-order pharmacy. Some plans provide up to a 50% discount over the cost of buying medications monthly. 

If you take Tier 3-5 maintenance medications and have already met your yearly deductible, consider having your prescription refilled (ideally, with a preferred mail-order 90-day supply) before year-end. 

Finally, if you are diabetic and use insulin, you should definitely check to see using the Medicare Plan Finder, if your current and/or other available MA plans for 2022, offer a low-cost insulin program. These plans offer select, brand-name insulins for as low as $50 for a 3-month supply. For more info go to: Medicare Plan Finder,  www.aace.com

Vaccines 

Many FDA approved adult vaccines are covered in full with no co-pay or deductibles through your plan’s network of providers (PCP, pharmacy). These include flu, pneumonia, Hepatitis B, Covid-19 virus, Covid-19 diagnostic and antibody. However, not all plans treat other important FDA approved vaccines that prevent illnesses (shingles, tetanus, diphtheria and pertussis) the same. Many insurers requirer deductibles and Tier 3 pricing

So, you should confirm your coverage with your plan before receiving vaccines and be aware that a number of MA insurers cover other important vaccines, but place them in Tier 3 (ex. shingles and tetanus) and as a result, subject you to a deductible, up to $350+, and higher co-payments than other approved vaccines.

This means you can have insurance coverage for vaccines, but you may have to pay up to the full cost for specific vaccines.

And, if you are 65+, make sure you receive the high-dose flu vaccine (unless contraindicated) that produces substantially more antibodies than the regular dose vaccine.

Preventative Dental Care

In recent years, a number of MA plans have added preventative dental care to their plans with no co-pays. While the plan marketing materials emphasizes two “free” cleanings, xrays and exams a year, they don’t mention the limitations. A common restriction to this “free” benefit is that it has maximum fee that the plan will pay your provider for each service/procedure and often full payment coverage is limited to a low negotiated fee agreed to by a small group of in-network dentists. If you go to your regular dentist and they don’t accept your plans’s rate, you will need to pay for the service out-of-pocket and then submit a claim to your insurance company and they probably won’t pay for more that the plan’s negotiated rate with their in-network dentists.

But, if you haven’t used up the dental allowance and not had your 2 cleanings this year, check with your dental office and either book an appointment before year-end (and you can decide if you really need the cost of a second exam and set of xrays) or ask to go on an appointment cancellation list. This is another use it or lose it benefit.

Eyewear/Contact Lens Allowance

Most insurance plans have an eyewear/contact lens allowance. The amount of the allowance varies by insurer from $75 to $300/yr. and is usually tied to the premium that you pay. This benefit is another use it, claim it, or lose it. There is no rollover of the benefit to the next calendar year and you usually need a recent eye exam prescription to order your eyewear or contact lens.

If you have a simple lens prescription, there are many options for ordering what you want/need online at reasonable prices for both contacts & eyewear. Examples can include regular & prescription sunglasses, reading glasses and stocking-up on contact lenses.

Healthy Living Rewards

Many plans include incentives for healthy living because they attract healthier customers that use fewer medical services and cost the insurance company less to serve. Some plans offer rewards up to $200/yr. in debit cards for taking brief online classes, getting a flu shot, completing surveys, having an annual physical, mammogram, colorectal & PSA screenings, vision test, use of a gym etc.

As with many benefits, you need to earn the rewards, report them, claim them or lose them. There is no roll-over of unclaimed rewards to the following year.

Over-the-Counter Medications/Supplies

Some MA plans also include an allowance of up to $100 a year for over-the-counter medications and supplies. However, there are a number of procedures to complete along with restrictions and limitations that vary for each plan. For example, some plans advertise a $100/yr. benefit, but the fine print states that it is limited to $25 a quarter with no carry-over of the unused benefit.

So, check with your insurer for the benefit details, limitations and procedures for claiming your rewards.

Telehealth Consults

The latest fad embraced by health insurers is virtual visits for primary and urgent health care. Over the past two years with Covid-19, telehealth consults took off, out of necessity and now are becoming mainstream. It’s been added to many MA policies with low, or no co-payments. However, time will tell how satisfied consumers are with the experience, quality and cost-effectiveness of this service. But, it’s here and you should consider it, as another option with obvious limitations, but available for you to try out. 

How to Choose the Best Medicare Plan for You?

October 15th is the start of Medicare’s Annual Open Enrollment Period that runs through December 7th. During this time, Medicare subscribers can make changes from their current plan.

Changes can include joining or changing:

  • a Medicare Advantage (MA) plan;
  • a Medicare Supplemental (Medigap) plan;
  • a Prescription Drug Plan (PDP) or
  • returning to original Medicare coverage.

Background

Original Medicare is the government run health plan for seniors and disabled people that utilizes private doctors, hospitals and other service providers.

By comparison, Medicare Advantage plans, Prescription Drug plans and Medicare Supplemental plans are all run by private insurance companies. These including a variety of for-profits (eg. UnitedHealthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some individuals maybe eligible to receive their health insurance, as a retiree or spouse, through their former employer. Service veteran may be eligible for health care and/or medications from the federal department of Veteran Affairs. And, many people may be eligible for federal, state or county financial assistance with the cost of their Medicare insurance, medical services and medications.

The Importance of Having a Good Medicare Plan

Selecting the best plan for you or your family member is a very important responsibility since the consequences can be significant both to your pocketbook and your ability to receive needed health care from your preferred providers.

However, the vast majority of people seldom make any changes in their insurance unless a crisis occurs. Your decision to stay or change your insurance plan in the Fall, generally results in a year long commitment, with few exceptions.

The Importance of Objective, Comparative Plan Information

Consumer Reports provides over 7 million subscribers with independent, comparative information and ratings of thousands of products and services. This information has proven to be highly valued by prospective buyers for over 70 years.

Health insurance is a billion dollar,  very profitable private industry with millions of dollars spent on marketing and sales. Understanding the complexities of different health insurance options and eligibility for financial assistance is a very challenging task. People should look for assistance early from knowledgeable family, friends, non-profit agencies and trusted insurance agents who have a proven track record of working in the best interest of their clients.

Keep in mind, the print and TV advertisements, written literature and presentations that you receive from insurance companies and agents are aimed at selling you their policies for a commission. They are not assessing your medical needs, priorities, budget, comfort with risk and then sharing with you, all of your options including products and services that they don’t receive a commission.

An insurance broker, who represents multiple companies, may provide you with broader options but is still making their living by selling the plans they represent, not providing you with objective, comparative information to help you make an informed decision.

How to Avoid Problems and Select the Best Plan for You.

  1. Invest time to become aware of the services your buying, what is excluded and your full costs as you would for any major purchase or commitment.
  2. Define your current medical needs
  3. Identify any upcoming or potential for major tests, surgeries or intensive treatment you are likely to need in 2022.
  4. Prioritize your preferences – what is most important to you?
  5. List your preferred service providers ( eg.doctors, hospitals, pharmacies)
  6. List out your generic and brand-name medications and their costs.
  7. Define your travel plans for the next year.
  8. Define what you can afford to pay for your insurance and health care.
  9. Compare your Medicare plan options and their advantages, disadvantages and cost:
  • Original Medicare (no prescription drugs included)
  • Part D Prescription Drug plans needed with original Medicare and Medigap plans
  • Medicare Advantage plans with prescription drug plans
  • Supplemental (Medigap) plans
  • Employer plan (if available)
  1. What to look for in plans
  • Do your preferred providers have contracts with the plan(s) that you’re considering?
  • What is the extent and cost of out-of-network coverage? Will you likely need it?
  • What is the cost difference between in and out-of-network services?
  • Are all of your medications and preferred pharmacy covered and at what cost?
  • What are the plan’s premiums, deductibles, exclusions, co-pays and co-insurance rates?
  • What is annual Maximum Out-of- Pocket limit of your health care expenses?

Resources to Help You Evaluate Various Medicare and Prescription Drug Plans

  • Medicare.gov (800-633-4227), is an excellent resource with general information and specific help in evaluating the differences among Medicare Advantage and Prescription Drug Plans (which are used with original Medicare and Medigap plans). If you are not comfortable using a computer, ask for help from a family member, friend or social agency.
  • State Health Insurance Assistance Program (SHIP) (877-839-2675)  Medicare contracts with states, counties and non-profit organizations throughout the country to provide individuals with personalized education, support and assistance. These free services include comparative plan information, information regarding eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.
  • Medicare Rights Center (800-333-4114)  is a national, nonprofit organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs, and public policy initiatives. MCR helps people understand their rights and benefits, navigate the Medicare system, and secure the quality health care they deserve. 

From more articles on the political/economic dimensions of Medicare plans/policies and their impact on patients’ access to affordable, effective treatment go to http://healthplanadvisor.org.

Jim Sorrentino

Updated 10/13/21

Biden offers Proposal for Reducing the Cost of Prescription Drugs.

Sounds good, but the pushback from Big Pharma and the members of Congress, that they give millions to each year, will be huge.
Time will tell if there is enough congressional support to bite the hand that has been feeding them for decades. 

“Seventy-two Senators and 302 members of the House of Representatives cashed a check from the pharmaceutical industry ahead of the 2020 election This represents more than two-thirds of Congress, according to a new STAT analysis of records for the full election cycle.”

Last year, Big Pharma spent $14 million funding your Congressional representatives.

STAT 6/9/21

Are Your Generic Drugs Safe and Effective?

Ten facts your doctor and pharmacist probably didn’t share with you.

  1. Over ninety percent of drugs sold in America are generic.
  2. And, 80% percent of generic prescription drugs are manufactured in India & China along with the Active Pharmaceutical Ingredients (API) that are used in patented brand-name drugs.
  3. Drug manufacturing is one of India’s major industries. They have about  700 Indian drug manufacturing plants that employ tens of thousands of workers.
  4. Foreign-made generics are less regulated and sanctioned by the FDA, even when they have had substantially greater data integrity, sanitary, quality and manufacturing deficiencies.
  5. The FDA’s priority is approving new generic drugs to market faster. In 2019, over 1,200 new generic drugs were approved, while improvements in existing foreign drug manufacturing, safety and data integrity lagged behind.
  6. Neither you, nor your doctor, are likely to know where your generic medications are manufactured and if serious quality and safety deficiencies have been identified by the FDA.
  7. Pharmacies do not necessarily fill your prescription with the same generic manufacturers’ medication each time. They are commonly filled with whatever they have available, especially in mail-order and centralized pharmacy centers.
  8. The FDA approval of generic drugs is substantially less stringent than brand name drugs. And, not all generic prescription drugs are identical for the same conditions. They can differ in the potency of API and the inert ingredients that can result in substantial differences in effectiveness, side-effects and adverse reactions.
  9. The use of generic medications for certain serious medical conditions such as seizure disorders, blood thinners & bipolar disorders can have greater risks due to a narrow therapeutic range for the medication.
  10. If your generic drugs comes in an amber pharmacy vial (compared to an original manufacturer’s stock bottle), it probably doesn’t include the name of the manufacturer and the country of where the generic drug was made

The food products that you buy and eat include substanially more FDA mandated product label disclosures including the manufacturers’ address and list of ingredients than the FDA regulated generic drugs that you take daily (on blind faith) for your physical and mental health.

For more information and to learn what you can do, explore the references below.

                                             References

Bottle of Lies, 2019 by Katherine Eban

Amazon.com: Bottle of Lies: The Inside Story of the Generic Drug Boom  (9780062338785): Eban, Katherine: Books

TedMed: A Dose of Reality about Generic Drugs, 2020, Katherine Eban

              Search FDA Compliance Inspections & Warning Letters
https://www.fda.gov/inspections-compliance-enforcement-and-criminal-investigations/compliance-actions-and-activities/warning-letters
A Guide to Investigating Your Own Drugs, 2019 by Katherine Eban
                   The High Cost of Cheap Pills, 2019 Bloomberg News                                     (A four-part series covering a year-long investigative study of the generic drug industry)

PeoplesPharmacy.com

Kaiser Health News, 2019

The STAT, 2019

Updated post 10.27.20

Medicare Plans Offer New Discounted Insulin Prices, or Do They?

Medicare Prescription Drug Plans that are sold by private insurance companies in Medicare Advantage Plans and stand-alone Part D plans for people with Original Medicare and Medigap plans are funded largely under contracts with the federal government using taxpayers funds.

Here’s are 3 things in the fine print you need to know.

1. The new pre-election announcement of a “Part D Senior Saving Program” that lowers your out-of-pocket co-payments for insulin, doesn’t begin until January 1, 2021 and doesn’t include the millions of Americans who use insulin every day but are not on Medicare.

2. The progam is optional for government-funded Medicare plans to participate in and the specific insulin that your doctor prescribes for you may not be included in the plan that you select.

To illustrate, in the upstate NY, we have 30 Medicare Advantage plans offered by 5 different insurers. However, in reviewing the details of their plans, only Excellus BCBS and United Healthcare have chosen to participate in this special option that will benefit seniors and disabled people who need insulin to live.

The other insurers who sell federally subsidized Medicare plans but chose not to participate in this insulin option include: Aetna, Wellcare and MVP (a regional insurer).

In drilling down deeper into the participating plans of Excellus and United Healthcare, a few other differences were noted.

Excellus: offers 5 Medicare Advantage plan that have monthly premiums ranging from $0 to $255. However only the three of the higher prices plans ($79, $157 & $255/mo.) are participating in the savings program. The two plans with either $0 or $39 monthly premiums are excluded.

So, individuals who enroll in a $0 or $39 monthly premium plan will be subject to a $380 or $300 deductible and a $42 a month/ $84 for three month supply of insulin from a preferred pharmacy.

By comparison, individuals who enroll in one of the three higher priced Excellus plans will not be subject to a deductible and will pay $25 a month/ $60 for 3 month supply of insulin from a preferred pharmacy.

United Healthcare: offers 4 plans with monthly premiums ranging from $0 to $79 a month. All of their plans include the insulin saving plan with an insulin cost of $35 a month/$95 for 3 months from a preferred pharmacy until you enter the catastrophic phase of medication expenses.

Finally note….always confirm that all your health care providers participate in any health insurance plan you are considering and that the medications that your doctor and you feel work best for you are also included in the plan’s formulary.

And, don’t be distracted with the marketing of $0 premium plans and extra free benefits that you may never qualify for or use. Spend some time shopping and comparing plans based on your most critical health care needs and the cost you’re likely to experience in the coming year.

There are two common problems that I see with clients….some are gamblers and they are under-insured even when they can afford to be safer.

And there are others that are too complacent and continue to stay with the same insurer/plan for 10 plus years even when their needs and income have changed. They are spending too much on insurance and don’t have enough money for other basic needs.

Look at the options that are available to you and make a choice that allows you to sleep at night.

Best wishes and stay safe and well.

Jim Sorrentino

What to Know When Selecting a Medicare Prescription Drug Plan

Background of Private Medicare Prescription Drug Plans

  • Legislation design by the President G.W. Bush administration and approved by Congress in 2003, resulted in the creation of a new privatized Medicare prescription drug (PDP) and Medicare Advantage (MA) plans for millions of elderly and disabled individuals. However, there was no responsible plan to pay for it. No new federal revenue sources were included nor were there cuts to existing federal expenses. Instead, federal subsidies were authorized for these new privatized Medicare benefits and these private insurers could also retain profits above and beyond their costs.
  • Traditional Medicare insurance which was already serving over 40 millions Americans in 2003, was not allowed to offer prescription drugs or other new benefits that private Medicare Advantage plans included.
  • It should also be noted that private insurers are allowed to pick and choose where and how long they want to sell plans compared to Traditional Medicare that is available to everyone that is eligible in the country.

  • As a result, two new publically funded, private health insurance plans were sold to the public on the assumption that they would cost less than Traditional Medicare and provide more benefits. However, today Medicare Advantage and PDPs cost taxpayers $328 billion/annually in federal subsidies.
  • The 2003 legislation also prohibited Medicare from negotiating drug prices on behalf of subscribers (as is done with the VA and Medicaid) and outlawed the importation of prescription drugs from Canada and other countries where they are sold at lower prices. As a result, prescription drug costs have sky-rocketed over the past 15 years.
  • Today, 43 million people are enrolled in private Medicare Part D drug plans either in stand-alone PDP how many people or integrated within Medicare Advantage plans.
  • In addition, the federal Social Security Administration subsidizes the cost of private insurer PDP premiums, deductibles and medications for 13 million low income individuals. This represents 28% of all PDP enrollees.

Important Facts to Know about PDPs

  • Today, the vast majority of Medicare Advantage Plans today include prescription drug coverage. However, Traditional Medicare and private Medicare Supplemental (Medigap) plans don’t include drug coverage, so a separate private PDP is needed for your medications and to avoid a potential late enrollment penalty.
  • Medicare-approved stand-alone PDPs are sold primarily by large, for-profit insurers such as Aetna/CVS, Cigna, Humana, SilverScript, United HealthCare and WellCare.
  • Private insurers are allowed to charge subscribers plan premiums, deductibles and co-pays/co-insurance for medications in addition to the federal subsidies that they receive.
  • Insurers also exclude specific drugs from their formulary, establish restrictions, such as requiring prior insurer authorization, limit medication quantities and require that subscribers take lower-cost drugs before higher-cost drugs.
  • Each insurer establishes their own drug classifications into pricing tiers and there are significant differences among PDPs regarding the drugs that are excluded/included and the premiums, deductibles, co-pays/coinsurance that subscribers are required to pay.
  • Although PDPs are not allowed to deny coverage or charge higher premiums to subscribers with pre-existing conditions and chronic diseases, insurers have latitude with establishing restrictions and subscriber charges.
  • There are no annual maximum out-of-pocket expenses for prescription drugs in either Medicare Advantage or stand-alone PDPs, so the cost of drugs can create serious financial problems for families.

  • In a 2019 study, reported in Health Affairs Journal, more than half of seriously ill Medicare enrollees face financial hardship with their medical bills with the cost of prescription drugs being the leading problem.
  • Unlike the rest of the developed world, in the US there is no public insurance for medications or government negotiation of drug prices, with the exception of the VA and Medicaid. As a result, the cost of medications to treat millions of Americans with life-threatening and disabling diseases such as diabetes, cancer, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, organ transplants are the highest in the world.
  • The cost of medications has become a huge burden on taxpayers; federal, state and local governments; employers; patients and families. This results in more costly health care with poorer outcomes, increases in disability, reduced work productivity and results a major cause of personal bankruptcies in the US.

A  Review of PDPs Available in Rochester, New York

Popular plans offered by Aetna/CVS, Cigna, Express Scripts, Humana, SilverScripts, United HealthCare (UHC)  and WellCare reveal the following observations.

  • Each insurer generally offers 3 plans with different premiums and deductibles. Premiums range from Humana’s Walmart Value plan $13.20/mo. with a $435 deductible, to SilverScript’s Plus plan $91.20/mo. with a $0 deductible.
  • It is common that low/no premium plans have higher deductibles, co-pays/co-insurance and limitations.
  • Only 3 plans have no deductibles (down from 7 plans in 2019) but all have high premiums. The 3 plans include SilverScript Plus with a $91.20/mo. premium, United HealthCare AARP Preferred with a $85.60/mo. premium and WellCare Value Plus with a $76.60/mo. premium.  These plans are not affordable for most people, since the average annual premium is over $1,000 and doesn’t include the cost of your medication.
  • All insurers have developed strong financial disincentives for subscribers who use “non-preferred” brand name and generic medications by establishing medication exclusions, deductibles and up to 50% co-insurance for non-preferred brand name Tier 4 drugs.
  • Many insurers also charge higher prices for “standard” versus their “preferred” and “mail order” pharmacies. However, insurers are generally weak in informing current and prospective enrollees of the cost differences among pharmacy options.
  • There are significant differences among insurers in specific brand name drugs that are either excluded from their formulary or placed into either Tier 4 or Tier 5. And, there are differences among insurers regarding the price of T4 non-preferred brand name  vs. T5 specialty medications. To illustrate, it is not uncommon that T4 non-preferred drugs are billed at a high rate of 32%-50% compared to T5 speciality drugs that are billed at 25%-33%. 
  • An insurer’s “Preferred generic and brand name” medications are not the most cost-effective medications with the least side-effects. “Preferred” medications reflect the deals that the insurers have made with the pharma companies to push their drugs over their competitors drugs.
  • This often occurs with medications for common conditions including rheumatoid arthritis, multiple sclerosis, diabetes and various neurological, cardiovascular, inflammatory, autoimmune and respiratory diseases and cancer.

  • Issues of drug cost, insurance prior approvals and access to treatment is a major source of conflicts among insurers, physicians and patients. So, it is very important to compare plans to understand the differences in coverage, restrictions and cost among plans that you are considering.

In summary, in considering PDPs it is important to confirm if the plans:

  • Do they include your medications and at what cost?
  • Is there a deductible expense on your drugs?
  • What restrictions are imposed on your prescribed medications?
  • Does the plan have preferred retail and mail-order pharmacies?
  • What is the reputation of the insurer with your doctors and pharmacies?

And finally, what is the total annual cost to receive your medications from each plan and the comparative differences in the PDP quality, costs and benefits.

Resources

Free resources are available to help you in comparing costs, coverage and quality ratings among plans. These include:

Medicare Plan Finder

Provides detailed information from Medicare to compare Quality Star ratings, your estimated annual and monthly cost (premiums, deductibles, co-pays/co-insurance) for your specific medications and pharmacies among available Prescription Drug Plans and Medicare Advantage Plans sold in your community.

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State Health Insurance Assistance Program

Provides free personal and group information/assistance with Medicare issues and questions.

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MedicareRights

Helps people with Medicare understand their rights and benefits, and navigate the Medicare system

References

Congressional Budget Office, 2019 reports

Center for Medicare & Medicaid Services (CMS)

Health Affairs Journal

Kaiser Family Foundation, 2019 Data Briefs and Fact Sheets

Medicare.gov

Medicare Rights Center

Medicare Trust Fund Board of Trustees, 2019 Annual Report

 

 

How to Avoid Costly Mistakes in Choosing a Medicare Plan

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Medicare’s annual open enrollment runs from October 15th to December 7th. During this time, Medicare subscribers can join or change plans including:

  • Medicare Advantage plans:
  • Return to the original Medicare coverage
  • Medicare Supplemental (Medigap) plans;
  • Part D Prescription Drug plan

It is very important to make an informed choice of the best insurance plan for your medical needs, preferences, and budget. A bad choice can cost you thousands of dollars and prevent you from receiving services that you need from your preferred providers.

Medicare Insurance Options for Seniors

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Original Medicare is the government-run health insurance for seniors and disabled people that use private doctors, hospitals and other healthcare providers.

By comparison, Medicare Advantage (MA) plans that often include a prescription drug plan, stand-alone Prescription Drug plans (PDP) that are used with original Medicare and Medigap (Supplemental) plans are all sold by private insurance companies that are subsidized and regulated by Medicare.

These plans are offered by a variety of large for-profits (eg. United Healthcare, Humana, Aetna), national non-profit organizations such as Blue Cross and many regional non-profit insurers.

In addition, some seniors are eligible to receive their health insurance through their current or former employer.  And most Veterans are eligible to receive their health care and medications through the Veterans Administration.

Common Problems to Avoid

Your plan doesn’t include your preferred service providers.

If you don’t verify that your health care providers have a network contract with the insurer that you are considering, you could be facing huge bills. You could be responsible for paying the full cost of expensive services from health care providers or declined service.

Out-of-Network does not mean out of your area. Your preferred health care provider could be next door, but may not have a contract with your insurance company.

Be especially cautious of PPO plans, often sold by national insurers, that lead you to believe that you can go to any doctor anywhere. This is not accurate. Many times national insurers have not developed local provider networks or formal contracts. They often pay commissions to insurance agents to sell policies but do not have local staff to resolve provider and subscriber issues and concerns. These are often handled by central call centers.

The fine print in PPO plan documents includes this disclaimer: “Out-of-Network/non-contracted providers are under no obligation to treat plan members, except in emergencies”

This means that while you may have insurance, you may not be able to find a provider that accepts your plan, for a variety of reasons.

You Didn’t Anticipate High Deductibles and Out-of-Network Costs

Some plans, such as the Aetna Elite PPO are advertised as a $0 premium plan, however you need to pay the first $1,000 for many medical services plus an additional $350 deductible for Tier 3,4 & 5 drugs  including vaccines that do not have a generic equivalent. In HMO plans, you could be responsible for the full cost of “out-of-network” services.

Consumers need to be aware that each insurer decides what drugs to include and exclude, and what they will charge subscribers. Generally, you will be responsible for the full cost of medications that are not included in the plan’s formulary.  Drug prices can also vary by the pharmacy that you choose and if you choose a 90 day mail-order supply versus a more costly monthly supply.

In considering plans, you should not focus solely on the advertised premium cost, but rather your medical, drug, out-of-network needs and your projected out-of-pocket expenses including premiums, deductibles, co-pays, out-of-network charges and drug costs.unknown-1

Medicare.gov provides a  “plan finder” that helps you analyze medical & drug expenses among various plan options that are available where you live.

 

 

You Didn’t Consider Medigap Plans for High Medical Expenses and Maximum Choices

Many Medicare Advantage HMO plans have little or no out-of-network coverage and you may have to pay for the full costs of services that you receive. If you have serious medical conditions that require costly tests, hospitalization, nursing home rehabilitation, outpatient


surgery and intensive outpatient treatment such as cancer, heart disease, renal disease and/or you would like the freedom to select specialty providers outside of your plan’s network, you’ll need good coverage at an affordable price. “Original Medicare” has no limit on your annnual expenses. And, Medicare Advantage plans have a high annual maximum out-of-pocket limit of $6,700 but there is an alternative–Medigap plans.

As a general guide, if your projected annual out-of-pocket medical expenses (premiums, deductibles & co-pays – excluding your prescription drug expenses) exceeds $3,000/yr. and/or you want Medicare coverage across the country, you should explore a Medigap plan.

Medigap plans provide supplemental coverage to original Medicare and pays for deductibles and copays. All healthcare providers who participate in Medicare across the country are included and there are no out-of-network exclusions or surcharges.

Medigap plans are regulated by each state and you can receive information on the availability of plans and their premiums by contacting your state insurance department medicare.gov/contacts.

You Didn’t Think You Needed or Understood Differences in Prescription Drug Plansmed prices

Most Medicare Advantage plans include prescription drug (Part D) coverage. However, if you have “Original Medicare” with/or without a Medigap plan, you will also need to purchase a prescription drug plan (Part D) unless you have an approved employer drug plan or receive your medications from the VA.

If you don’t have a an approved drug plan and you want to purchase one at a later date, you are likely to be subject to a late enrollment penalty.

Part D plans are sold by private insurance companies and vary from state to state. For example, in New York State 27 plans are available from 10 different insurers. The premium and deductible cost of plans in New York varies widely from a Humana Walmart plan that costs $13 a month with a $435 deductible to a SilverScript plan that costs $91 a month with no deductible.

It is also important to check plans that you are considering to confirm that the medications that you need are included and what your co-pays and total annual expenses will be before enrolling in a plan.

Medicare.gov has a planfinder that compares the different cost of the various Part D plans based on the medications that you use and where you live.

You Didn’t Expect a Medicare Enrollment Penalties

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Medicare rules require that if you want to receive Medicare benefits, you need to enroll and pay your Medicare Part B (outpatient) and Part D (prescriptions) premiums when you are first eligible. There are a few penalty exceptions, for example, if you receive creditable medical and drug insurance from you or your spouse’s employer, if you receive your medications from the VA.

Medicare penalties can be significant. The Part B (outpatient care) late enrollment penalty is 10% for each year, from the date of your initial Part B eligibility. The Part D (prescription drugs) penalty is 1% for each month from when you were initially eligible, or June 2006, the start of the program. There are a few circumstances when penalties can be reduced or eliminated.

The Importance of Having a Good Medicare Plan

Selecting the best plan for you or your family member is a very important responsibility since the consequences can be significant, both to your pocketbook and your ability to receive needed health care from your preferred providers.

Investing time in planning and seeking objective advice in selecting a plan, can save you a lot of time, money and headaches. The following is a list of free resources that are available to help you.

Resources

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Social Security Administration, socialsecurity.gov, 800-772-1213

The Social Security Administration is the agency that you need to contact to apply for your Social Security benefits and enroll in Medicare Part B and D., In addition, you can be screened for eligibility (income and resources) and apply for “Extra Help” with your Part D premium and cost of your medications

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Medicare: Medicare.gov – 800-633-4227

An excellent resource with Medicare information and specific help in comparing Medicare Advantage and Prescription Drug Plans in your area.

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State Health Insurance Assistance Program  SHIP 877-839-2675

Medicare contracts with states, counties and nonprofit organizations to provide individuals with personalized education, support, and assistance with Medicare.

These free services include comparative plan information, eligibility for financial assistance as well as help with selecting a Medicare plan, enrolling, and resolving problems.

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Partnership for Prescription Assistance

 This is an online information resource tool. You can learn about assistance programs that are available for specific medications, along with the eligibility criteria and program applications.

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Medicare Rights Center, medicarerights.org , Helpline: 800-333-4114

The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educational programs and public policy initiatives.

 

This article was updated in October 2019 from an earlier post.