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. 

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

Eight Things You Need Know about Medicare Prescription Drug Plans before Enrolling

 

  1. Medicare pays private insurance companies $95 billion each year in subsidies for Prescription Drug Plans (PDP) in addition to what enrollees pay in plan premiums, deductibles and co-pays for your medications.
  2. There is no annual limit on your out-of-pocket prescription drug expenses that are sold by private insurers.
  3. Private insurers control their drug expenses by restricting your access to medications that your doctor prescribes through: their drug formularies that exclude specific drugs, require prior authorization, limit quantities, require you to take lower cost drugs before higher cost drugs are approved and by establishing their own drug price tiers, annual deductibles and the amount that you are required to pay for prescriptions.
  4. There are significant differences among Medicare Part D plans including: the drugs they include, what Tiers they assign to their included drugs, and the premiums, deductibles, co-pays and coinsurance that subscribers are required to pay.
  5. Although Medicare Part D plans are not allowed to deny coverage or charge higher premiums to people with pre-existing conditions, their prescription drug policies provide a clear message of who they want, and don’t want as subscribers.
  6. The cost of medications in the US to treat millions of Americans with life-threating diseases such as diabetes, multiple sclerosis, Hepatitis B, inflammatory diseases, respiratory diseases, various cancers, organ transplants are the highest in the world.
  7. Big Pharma and the insurance industry have been very successful in controlling Congress and the Executive branch with the millions that they pay each year in political campaign contributions and lobbying.
  8. In return, Big Pharma and the insurance industry has insiders working in key executive positions in government, such as the White House advisors, Congressional committees staff, Departments of Health and Human Services (Alex Azar), Center for Medicare & Medicaid Services (Seema Verma) and the Food & Drug Administration (Scott Gottlieb) where they use their industry special interest in writing federal legislation, establishing policies, regulations, administrative practices and weakening regulatory compliance and sanctions for violations.
  9. This situation results in higher taxes, huge goverment debt and the highest prescription drug costs in the world for life-threatening conditions that many Americans can’t afford.

Medicare DrugCost

A review of four major Medicare Advantage plan insurers in Upstate New York including for-profits: Aetna, United HealthCare and WellCare and regional non-profits: MVP and Excellus Blue Cross revealed the following observations.

  • All insurers target enrolling healthy seniors and provide incentives with low or no monthly premiums along with gym memberships.
  • All insurers have developed financial disincentives for individuals that are prescribed: “non-preferred” brand-name and generic medications, specific medications that they have excluded, requiring deductibles up to $380yr., medications that require co-pays up to $100 mo. and co-insurance charges of up to 33%.

In summary, you may have insurance for your prescription drugs in your private Medicare Part D Plan, but you may not have coverage or the ability to pay for your critically needed medications for life-sustaining treatment.

As result,  it is very important that you that you educate yourself and confirm that the Medicare drug plans that you considering meets your needs and budget during this Medicare open enrollment period that ends, December 7th.