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. 

Shingrix – The CDC Recommended Vaccine that Most Medicare Plans Cover, But Few will Pay for it.

Background

Shingles affects nearly 500,000 of Americans over 60, every year. It can be a very painful and debilitating condition. However it can be prevented with a vaccine. Shingles causes a rash with itchy blisters on your body along with shooting nerve pain. It can attack older adults’ as well as individuals with weakened immune systems as a result of chemotherapy, long-term use of steroids and other conditions.

Shingles can be contagious to people who have never had chickenpox or have not been vaccinated. People especially at-risk are pregnant women, newborns and children who have not been vaccinated.

The Center for Disease Control (CDC) has recommended Shingrix as the preferred vaccine because it is 90% effective in preventing shingles. The average cost of Shingrix is $300 for the two required vaccines and it’s effective for the rest of your lifetime.

In my work as a Medicare counselor in Rochester, NY (Upstate New York), I have reviewed the formularies of all 24 Medicare Advantage (MA) plans and 27 stand-alone Part D prescription drug plans (PDP) in Rochester service area.

And, here is what  I learned…….

  • All the MA and PDP include Shingrix in their plan’s formulary.
  • However, only one MA plan (nonprofit Excellus Blue Cross/Blue Shield), classified Shingrix as a Tier 1 vaccine with no premium, deductible or co-pay.
  • Other MAs offered by: Aetna/CVS, nonprofit MVP, United HealthCare and WellCare that have monthly premiums ranging from $0 to $350 and deductibles ranging $0 to $395 listed Shingrix as a Tier 3 drug
  • All of the 27 PDPs offered by: Cigna, Emblem, Envision, Express Scripts, Humana, Magellan, JourneyRX, Silverscript, United HealthCare and Wellcare also classified Shingrix as a Tier 3 vaccine with monthly premiums ranging from $13.20/mo. with a $435 deductible to a plan with a $91.20/mo. premium and no deductible.

Conclusion

The bottom line is (with the exception of Excellus Blue Cross) 50 private Medicare drug plans that are under contract with Medicare and receive generous subsidies, include Shingrix in their formulary, but classifying it as a Tier 3 drug make it subject to a deductible that is equal to the price of the vaccine. As a result, you are paying for the full cost of the CDC recommended vaccine and these 50 insurers are paying nothing.

At the same time, The President and Congress give away $95 billion a year of taxpayer’s money to subsidize private insurance companies that sell private Medicare policies. In return, the insurance and pharmaceutical companies pay over $ 9 million a year in campaign contributions to candidates and members of Congress.

Final Thoughts

This is just one of many examples, that illustrates how American health care services are the most costly in the world with the poor outcomes due to unethical practices that have become commonplace on the part of elected and appointed officials, insurance and pharmaceutical companies.

Medicare insurance policies and contracts need to be reformed to make them rational, sustainable and cost-effective. And meaningful ethical standards need to be established, monitored and enforced. Science and accepted clinical evidence needs to replace the dominance of the financial self-interest of elected and appointed federal office holders and the billion dollar insurance and pharmaceutical industries.

If you want to see the Medicare insurance system change, let your elected federal representatives and candidates running for office in 2020 know your views. Remember you pay their generous federal salaries and benefits and it is their job to represent the common good of the people that they are expected to represent.

And, if you plan to get a Shingrix vaccine soon, first check the coverage and cost of your current plan and other available insurance plans in your area. You have the opportunity to change your Medicare plan for next year by December 7th.

Be the change you want to see.

In the interest of full disclosure, I am not compensated or have a relationship with any insurance or pharmaceutical company mentioned in this article.