Anyone understand the new Medicare Prescription Drug Plan?

[Bob Weisner]

Hi:


Does anyone understand the new Medicare Prescription Drug Plan? For the people that get automatically signed up, are they getting a good deal or are there better plans out there? My concern is that people that are automatically signed up to a given plan may not be getting the best of deals , but the cheapest of plans.

Any opinions?


Thanks,

[Dennis Peacock]

An opinion? You're asking someone who is getting royally raked over the "coals" on medical health benefits come Jan 1, 2006....thanks to the new Lumenos plan that many corporations are taking to because it saves THEM money while costing each associate/employee a bundles each month out of their own pockets.:mad: :mad: :mad:

From my understanding is that the wording of the new plans are such that it takes a small army of lawyers to figure it all out.:confused: :(

[Michael Perata]

I still have three years before it becomes a major thought exercise. :rolleyes:

If you do manage to figure it before 2008, please post a synopsis of your understanding. ;)

[Joe Pelonio]

I have still not found anyone that understands it. My wife contacted the Medicaid case worker for her Mom who is 86 and in an adult family home for help, and so far even she has not been any help. Apparently the state is hoping to save money by having the fed program take up much of their current drug expense so they'd prefer you get the most expensive plan but they are not allowed to say that.

[Gary Whitt]

There's like 48 levels of coverage.

Both of my parents (73) just guessed at which fit them the best.

Mom is on 5x the number of medicines that dad is on. :(

[Jim Becker]

The folks that are going to have a real challenge are those (especially couples) who take a lot of different medications from different manufacturers. Each "plan" has a different formulary, and since the drug companies are involved in the plans, "competitive" issues could come into play. I really like the idea of prescription coverage because drugs are often the most financially challenging boat-anchors to many retired folks (as well as more and more younger families), but IMHO, there are too many special interests for this to be fair to even "most" people.

GMA did a piece not long ago on the complexity of the new system and it was stumping some "really smart" people whom they had take a look at it in detail.

[Bob Weisner]

I think that the part of the new plan where people have to pay $3,600 "Out of pocket" is going to put a financial hardship on the Senior Citizens that can afford it the least.

[Joe Pelonio]

I just talked to my wife about her mother. All she knows is that the plan she signed up for has a $1-$3 per prescription co-pay. If that's true we'll just leave an advance payment credit on her account at the pharmacy to cover them and they can call when it gets low. The guy that runs the adult family home picks up, stores, and distributes all drugs. He apparently did study the whole thing and recommended whatever plan this is as the best for her. Trouble is apparently that if new drugs come out and are prescribed or a person gets some other different medical problems the plan they are in may no longer be the best. What a mess.

[Joe Mioux]

An opinion? You're asking someone who is getting royally raked over the "coals" on medical health benefits come Jan 1, 2006....thanks to the new Lumenos plan that many corporations are taking to because it saves THEM money while costing each associate/employee a bundles each month out of their own pockets.:mad: :mad: :mad:

From my understanding is that the wording of the new plans are such that it takes a small army of lawyers to figure it all out.:confused: :(

Hey Dennis, want to trade plans?

Self employed businesses have some downsides. One of which is providing health ins for his 4 kids, wife and himself with really high deductibles and even higher prems.

My dad and I were discussing this senior healthcare program this morning. He is confounded by its complexity. Although knowing my dad, he probably just skimmed it and is waiting for the "Cliff Notes".

Joe

[Boyd Gathwright]

Hi Don,

.... Well put :p. Here is the other original thread to this:

http://www.sawmillcreek.org/showthread.php?t=26986



Big government at work. What could we expect when Congress writes the plan? Take a bunch of guys regardless of party whose main concern is getting re-elected and this is what you get. Nothing is going to change until we get term limits so those guys will pay some attention to something besides getting re-elected.

[Tim Wirtz]

I think that the part of the new plan where people have to pay $3,600 "Out of pocket" is going to put a financial hardship on the Senior Citizens that can afford it the least.

That is only with some of the plans. Depending on the premium you wish to pay each month and the level of coverage you want, you can get plans that don't have the 3600 gap. These plans are more expensive (37.50 to 99.90 per month in Minnesota) but they do cover the 3600 gap.

Bob, in the research I have done on my own (on behalf of an uncle that age) and at work (I work for a health insurance company), I have found that the plans vary greatly by company but seems that the more expensive the policy, the more drugs are covered under their "formularies". The biggest difference here is the number of participating pharmacies one can choose to go to with the different plans. One company in this state will let you go just about anywhere while another one has a VERY limited set of pharmacies they consider "in network".

I would really advise anyone who can to go to the Medicare website (www.medicare.gov (http://www.medicare.gov)) and use the tools on the site. I understand that it is slow and somewhat tedious to use but it does have the most comprehensive information for medicare recipients based on the location in which they live. Also, even though it may take some time out of your day, it could literally save you or someone you know of this age group THOUSANDS of dollars. Be sure to have a list of the drugs you currently take and the generic names if available, as this will be used to determine which plans are right for you. Also remember that you still have some time to register. The cutoff date for registering is May 15th, 2006 or within a certain time frame if you retire after 1/1/06. That being said, don't put it off past the deadline as the premium you will pay when you do sign up will go up by a percentage per month.

Some insurance companies also have very good question and answer lines and, in one case, I got an actual person answering the phone instead of an automated directory. I was so flabbergasted when someone actually said, "Hello, this is so-and-so with X insurance company.." that I was mometarily speechless.

I know this is stuff you have probably already heard but, as one who deals with it for a living, this is the best overall information I can give you, especially considering the number of plans available and the differences in them.

Hope it helps.

Tim

[Ken Garlock]

Bob, for me it was simple beyond my wildest dreams.;)

My secondary health insurance from TI is managed by BCBS of Texas. I got a booklet from TI which explained it in terms even I could understand.

1. Our prescription plan is equal to or better than the Medicare prescription plan.

2. If you sign up for the Medicare prescription plan, we will drop you from our medical insurance plan without recourse.:eek:

Even the brain dead can understand that. :)

[Frank Hagan]

Political content removed by Moderator

Anyway, I'll have to get the list of drugs my mother uses and start wading through this thing. Not a pleasant task, I'm sure.

[Bob Johnson2]

There was just an artical about it in the WSJ, pretty much echo's what Tim and Ken say.
1st thing is sign up for something by May 15th.
2nd thing is if your current plan is better or as good, keep it. The plan needs to be "creditable" so you won't get penalized later if you change plans. Doesn't say what "creditable" is though!
Along with using the medicare.gov site you can call 1 800-medicare for a live person (good luck) to run your drugs and see the best plan.
If you have to just pick one that's cheap, just get something by May 15th. If you wait till after the payments are higher.

So says the WSJ.

[Tim Wirtz]

2nd thing is if your current plan is better or as good, keep it. The plan needs to be "creditable" so you won't get penalized later if you change plans. Doesn't say what "creditable" is though!

So says the WSJ.

Credible is a term the industry uses to state that the plan their members are on is as good or better than the basic plans under part D. It doesn't mean they are better then the BEST plans offered by some insurance companies. Every insurance company in the US was required by law to send out a Credible Coverage letter to all its members of retirement age stating whether or not their coverage under the company's plan was as good or better than Medicare's basic plan. My company sent it to everyone regardless of age. I am 37 and got one. As the WSJ reported, a person currently enrolled in a Credible Coverage insurance plan CANNOT be penalized with higher Medicare Part D premiums if they drop their current coverage at a later date and then choose Part D, so long as they choose the Part D plan within a specified time frame after cancellation of their other coverage.

Slightly off topic, most people are familiar with the Medicare Part D part of the Medicare Overhaul of 2003 (called the Medicare Modernization Act)but most are not aware of the other major changes made to Medicare in that bill. One of the biggest was the further inclusion of the private sector in Medicare. For instance, insurance companies are now allowed to act on behalf of Medicare in some situations by offering plans that include all the benefits of Medicare plus extras that Medicare doesn't cover traditionally. These plans are called Medicare Advantage plans and offer a Medicare benificiary an easier way to have claims paid. For instance, the patient can now go to a clinic and the clinic can bill the insurance company directly without having to send the bill to Medicare first. The insurance company applies Medicare's benefit and then any extra benefits under the insurance's plan. The clinic doesn't have to wait for payments from two sources and so it reduces the chances of clinics asking for collections from the patient. It sounds like a good idea but it is a real headache for insurance companies to figure out all of Medicare's rules and regulations, not to mention their pricing methodologies. That's one of the things I am involved with. There are a lot more changes that will benefit Medicare recipients that I wish the press and government would elaborate more on. Again, check the Medicare website.

Good luck with the search for a plan that meets your needs.

Tim

[Jesse Cloud]

The insurance companies have all the cards here. First they get a huge subsidy from the government, then they get to set their own prices and policies. When I researched my mom's situation, many of her drugs (cozaar for example) were not covered at all in most plans, those that did cover it consider it a tier 2 or 3 or 4 drug and charge outrageous prices. And from what I understand, they can change their coverage any time, drop something or change the tier. Its way too complicated to make a rational decision. Its just like theoretically, if your doctor charges too much you can shop around - but practically that's very hard to do. Main beneficiaries here are clearly the pharmaceutical companies.
Additionally, its not hard to find better prices on the internet, but there is significant risk in buying prescription meds on the internet - lots of scams.
Good luck to all.

[Bob Weisner]

I just checked on one of these plans. The plan I looked at requires preauthorization from the insurance company to prescribe any medicine that would be used to treat Cancer. What good is a Prescription Drug Plan if you have to fight with the insurance company to get them to pay for medicine to treat Cancer?

[Frank Hagan]

The insurance companies have all the cards here. First they get a huge subsidy from the government, then they get to set their own prices and policies. When I researched my mom's situation, many of her drugs (cozaar for example) were not covered at all in most plans, those that did cover it consider it a tier 2 or 3 or 4 drug and charge outrageous prices. And from what I understand, they can change their coverage any time, drop something or change the tier. Its way too complicated to make a rational decision. Its just like theoretically, if your doctor charges too much you can shop around - but practically that's very hard to do. Main beneficiaries here are clearly the pharmaceutical companies.
Additionally, its not hard to find better prices on the internet, but there is significant risk in buying prescription meds on the internet - lots of scams.
Good luck to all.

It is pretty complicated, but I'm very thankful this thread came up. My mother hasn't chosen a plan yet. The advice to make a list of all the drugs and go to the Medicare site was a good one ... we're wading through the plans right now to see which is best. She's been buying all of her drugs directly, so the plan will probably help a bit.

They can drop a drug from their "formulary", but they have to give you 60 day notice, or allow you to buy a 60 day supply. They also have to allow you to buy the drugs in 3-month quantities for no more than three times the monthly cost (my mother's available plans have several that offer 90 day supplies for about half the cost of the 30 day supply). Then you can change plans during the "open enrollment" period. There's some good info on this type of stuff at https://ssl4.benefitscheckup.org/

[Frank Hagan]

I just checked on one of these plans. The plan I looked at requires preauthorization from the insurance company to prescribe any medicine that would be used to treat Cancer. What good is a Prescription Drug Plan if you have to fight with the insurance company to get them to pay for medicine to treat Cancer?

There's an expedited appeal process where they have to give you an answer within 24 hours, or the normal appeal process where they have to give an answer within 72 hours. So you can't be jerked around with this plan like with a regular prescription plan (I fought with my insurance for three months on one thing, and finally paid privately when they wore me down.)

I think the main thing is if you are spending more than about $50 a month on drugs, then one of the plans will save you some money. You'll still have up to $3,650 out of pocket before the 95% plan kicks in unless you are indigent.

[Frank Hagan]

Well, we just ran into a very strange thing.

One of my mother's drugs is "Potassium Chloride Tab 20 MEQ CR", and it's not on any of the formularies. If she goes on one of these plans, the cheapest she can get this drug is $28.26.

She currently has no prescription insurance, and pays $10.11 for the drug at the Costco Pharmacy. We're checking to see if there are others on the list where they co-pay is more than she is paying for the drug at normal rates.

[Jeffrey Schronce]

Slightly off topic, most people are familiar with the Medicare Part D part of the Medicare Overhaul of 2003 (called the Medicare Modernization Act)but most are not aware of the other major changes made to Medicare in that bill. One of the biggest was the further inclusion of the private sector in Medicare. For instance, insurance companies are now allowed to act on behalf of Medicare in some situations by offering plans that include all the benefits of Medicare plus extras that Medicare doesn't cover traditionally. These plans are called Medicare Advantage plans and offer a Medicare benificiary an easier way to have claims paid. For instance, the patient can now go to a clinic and the clinic can bill the insurance company directly without having to send the bill to Medicare first. The insurance company applies Medicare's benefit and then any extra benefits under the insurance's plan. The clinic doesn't have to wait for payments from two sources and so it reduces the chances of clinics asking for collections from the patient. It sounds like a good idea but it is a real headache for insurance companies to figure out all of Medicare's rules and regulations, not to mention their pricing methodologies. That's one of the things I am involved with. There are a lot more changes that will benefit Medicare recipients that I wish the press and government would elaborate more on. Again, check the Medicare website.

Good luck with the search for a plan that meets your needs.

Tim

Is the company then accepting all the premium and all the risk plus claim adjustment expense? Or is the portions of premium that would have been paid to Medicare passed to Medicare along with the related coverage claims and adjustment expense, ie acting as TPA for certain coverages?

[Tim Wirtz]

Jeffrey,

The answer is both or one or the other depending on which type of arrangement they have with Medicare. In some cases, the insurance company accepts partial cost and risk on outpatient services (Part B) only, while submitting inpatient, hospice,etc. (also known as part A) to Medicare. In other situations, the insurance company will process both Part B and Part A in a Medicare HMO platform. (Years ago this used to be called Medicare Choice, or Part C). In still other cases, they can act as as a Third Party Administrator (TPA). It really depends on the contract and the same insurance company can have multiple contracts with different payment arrangements. The basic premise, as far as a consumer is concerned, is that, in any of these arrangements, the plan offered by the insurance company cannot have benefits that would be less than Medicare would provide to the subscriber if they only had Medicare. What the insurance company CAN do is offer coverage for services that Medicare normally doesn't cover for an additional premium. Depending on the access to provider limitations, the additional premium can be very small (such as access to an HMO style provider network) or very large (such as a completely open network). Are you confused yet or just sleepy? http://www.sawmillcreek.org/images/icons/icon11.gif

There are many many details, limitations and rules that the insurance companies must follow in order to comply with Medicare's new programs and Medicare watches closely. All plans must have prior approval from CMS (Center for Medicare and Medicaid Services) before being sold to the public. This creates some safeguards for the Medicare recipients and lots of headaches for the insurance companies. Though I work for an insurance company, I really applaud these safeguards and think they save a lot of Medicare recipients a lot of problems.

OK, now you're REALLY sleepy.http://www.sawmillcreek.org/images/icons/icon10.gif

[Joe Pelonio]

Just got a call from the guy that owns the adult family home where my mother in law is. Turns out that after all the work and guessing the plan we put her on is not accepted by the pharmacy that he uses. Since they deliver and all the other residents use it he wants us to change her to another plan. So here we go again. We're going to start by talking to the pharmacy and see what they do accept. Geez.

[Boyd Gathwright]

-------- Original Message -------- <table border="0" cellpadding="0" cellspacing="0"> <tbody><tr><th align="right" nowrap="nowrap" valign="baseline">Subject: </th><td>Fw: Think About this One!</td></tr><tr><th align="right" nowrap="nowrap" valign="baseline">Date: </th><td>Fri, 6 Jan 2006 14:58:18 -0500</td></tr></tbody> </table>
Think About this One :rolleyes:!

A car company can move its factories to Mexico and claim it's a free market.
A toy company can out source to a Chinese subcontractor and claim it's a free market.

A major bank can incorporate in Bermuda to avoid taxes and claim it's a free market.

We can buy HP Printers made in Mexico. We can buy shirts made in Bangladesh. We can purchase almost anything we want from 20 different countries

BUT, heaven help the elderly who dare to buy their prescription drugs from a Canadian pharmacy. That's called un-American! And you think the pharmaceutical companies don't have a powerful lobby? Think again!

Please forward this to every person you know over age 50. It is an interesting point of view. Maybe this is an issue that should come up in the next election!

Forget the 50, send it to everyone We're all in this boat together!

[Jeffrey Schronce]

Jeffrey,

The answer is both or one or the other depending on which type of arrangement they have with Medicare. In some cases, the insurance company accepts partial cost and risk on outpatient services (Part B) only, while submitting inpatient, hospice,etc. (also known as part A) to Medicare. In other situations, the insurance company will process both Part B and Part A in a Medicare HMO platform. (Years ago this used to be called Medicare Choice, or Part C). In still other cases, they can act as as a Third Party Administrator (TPA). It really depends on the contract and the same insurance company can have multiple contracts with different payment arrangements. The basic premise, as far as a consumer is concerned, is that, in any of these arrangements, the plan offered by the insurance company cannot have benefits that would be less than Medicare would provide to the subscriber if they only had Medicare. What the insurance company CAN do is offer coverage for services that Medicare normally doesn't cover for an additional premium. Depending on the access to provider limitations, the additional premium can be very small (such as access to an HMO style provider network) or very large (such as a completely open network). Are you confused yet or just sleepy? http://www.sawmillcreek.org/images/icons/icon11.gif

There are many many details, limitations and rules that the insurance companies must follow in order to comply with Medicare's new programs and Medicare watches closely. All plans must have prior approval from CMS (Center for Medicare and Medicaid Services) before being sold to the public. This creates some safeguards for the Medicare recipients and lots of headaches for the insurance companies. Though I work for an insurance company, I really applaud these safeguards and think they save a lot of Medicare recipients a lot of problems.

OK, now you're REALLY sleepy.http://www.sawmillcreek.org/images/icons/icon10.gif

Nope, I am a complete and total insurance nerd. My wife was making fun of me for asking the question and actually caring about it! Most of my work is in P&C rather than L&H, however I have saw so many billboards, advertising, etc from companies seeking to provide "bundled" coverages, I was wondering how they were making their money. Elderly medical doesn't seem terriably profitable unless you are passing a lot of the risk over Medicare.
THanks

[Carl Eyman]

Many of you have read Bob's thread as well as my post of a couple of months ago. Let me post an update showing how a complicated situation can get worse. Yesterday the mail carrier delivered a USPS envelope with a small portion of a destroyed envelope in it. It was the upper left corner of an envelope with my return address. It had been mutilated by one of the machines. I had no idea what the original contents might have been. But, Lo and Behold, there was contents inside this envelope portion. It was a small corner of the application I had made for the Medicare Part D insurance. "No wonder" I said to self, "that I've not heard from the insurance company since I mailed this thing in late November". So today I re-applied on line. Since I needed a prescription refilled I did that this noon. Cost - $133.00.

This afternoon I got a call from the insurance Co. giving me my enrollment number. So the rest of the mutilated envelope went through! (I'm sure my on-line application did not trigger the call)

I called the pharmacy to see if the $133 was a lost cause, and to my delight found they could adjust things and the pills would cost me only $28.

What tool can I buy for the $105 balance?

I post this to give those that have followed these threads a sense that however complicated it seems, it can get worse, but that that $105 savings makes it all worthwhile.

[Frank Hagan]

We finally got through all the questions for my mother's coverage. The advice here to list all the prescriptions she takes, and then enter them at the Medicare site was, as I've said, invaluable to making it through the process.

Come to find out, for her, an AARP plan with no deductible was the best. Reduced her cost by about half starting with the first month.

I understand there is a penalty for not signing up by March 15. I think it amounts to a 1% per month higher premium.

I can't help but think that there will be a falling off of providers, and in the next few years we'll see plans dwindle down to just a few when the insurers decide that the plans are too expensive to offer.

[Vaughn McMillan]

Thanks Tim (and all the others) for the variety of information. I'm in the process of figuring out what plan LOML's mom (who lives with us) needs to sign up for, and the information here has given me a point from which to start. She's apparently got no perscription coverage currently, so she's been paying full price for her meds for quite some time. (I say "apparently" because even though she doesn't know about being on a plan, that doesn't mean she isn't on one and just not using it.) I'm starting to take on the role of "virtual" Power of Attorney, since LOML (who does have POA) doesn't really know the ins and outs of financial/insurance/legal stuff, and her mom's less able to understand it than any of the rest of us. I'm no wizard either, but I have a better chance of figuring this type of thing out better than LOML or her mom. The more help (like these posts) I can get, the better.

- Vaughn

[Frank Hagan]

Vaughn, there were a couple of things that confused us at first. You may not have these questions, but just in case you do ...

The monthly premium the insurance company lists is the only charge ... my mother was concerned that Medicare Part D also had a charge from Medicare. I think the confusion stems from the fact that you can either send payment to the insurance company you choose each month, or have it deducted from the Social Security check. Some seniors thought it was both of those, rather than an option of one way or the other.

There is a provision for "extra help" for indigent seniors that pays all or part of the insurance premium. Assets, either in cash or property, of more than $11,500 puts the person over the limit for the special help. There is an exemption for primary residence and one vehicle, but other land, savings accounts, etc. are all counted. My mother was confused and thought that the denial of the "special help" meant she wasn't eligible for the Prescription Drug Plans ("Part D"). Everyone who is on Medicare Part B is eligible, regardless of income.

If you find a drug that is not on the "formulary", and have a plan with a deductible, then you have to buy that drug through the program in order for that cost to apply to the deductible. If you buy it "off program", the cost doesn't apply. We were perplexed at first, because my mother has a drug she pays $3 for that is $28 on the "co-pay" for all the plans, because it is not on the formulary. So you have to decide if paying for it privately, or through the plan makes the most sense. In my mother's case, the AARP plan for Southern California doesn't have a deductible, so she can pay the $3 for the drug and not have to worry about qualifying for it.