Take two pills and call me in the morning

On Medicare? If so, you likely have a Part D drug plan. It may be built into your Medicare Advantage plan or it may be a stand-alone drug plan. Either way, you need to be vigilant to avoid overpaying for your prescriptions. In other words, don't blindly hand over your Part D drug plan ID card at your favorite pharmacy and hope you are getting the best price.

I've been enrolling people to Part D drug plans since 2006 when the government first started this program. I've used my own Part D drug plans since 2012 and have some tips and hints to make your experience better. Let me give you an example of what I mean.

Two women walk into a local Bartell Drugs in Seattle to fill their prescriptions, both pulling out their Medicare Part D insurance cards. One pays $27, but the other writes a check for $153 for the exact same drugs. Unbelievable? Not really. In fact, it happens all too often. There are several ways to avoid this situation.

#1 - know your plan and make sure all of your regular doctor-prescribed medications are in the plan formulary. You should have received one with your plan but you can also look it up online.

Tip: some formulary documents are 160 pages long. To look up your prescription, press the Ctrl key + the F key. That opens a dialogue box in the upper right-hand corner of the document (usually a PDF). Type in the exact name of your medicine. There should be an indicator showing either 0/0 meaning the drug is NOT in the formulary, or 1/6 (it could be 1/10 meaning the drug shows up in six or ten places). If there are numbers in the indicator you should see the drug listed on the page it took you to. You can hit ENTER to jump to the next listing, and so on.

Notice the number next to the name of the drug indicating which TIER level it is assigned: 1, 2, 3, 4 or 5. Tiers 1 and 2 are usually labeled generic, tiers 3 and 4 are brand name drugs. Tier 5 is often an injectable or doctor-administered drug.

#2 - understand the three stages of drug coverage: The initial stage which may have an annual deductible and then low copays, the coverage gap (donut hole) stage with higher copays and finally the catastrophic stage when your costs are very low. Have your professional agent explain these stages to you so there are no surprises during the year.

#3 - there are alternatives to using your Medicare Part D drug plan. Check the coupons available at www.goodrx.com and see if there is a less expensive way to purchase the medicine. A client was paying $161 for a 90-day prescription at a compound pharmacy using her Plan ID card. She found that the same drug was available for $70 at the Safeway pharmacy. She saved $364/year by using GoodRx instead of her Part D card.

#4 - prices can vary from pharmacy to pharmacy. All drug plans negotiate special arrangements with certain pharmacies - called "preferred pharmacies" - that let them offer better deals in those stores. Again, your Drug plan booklet should list the preferred pharmacies. If not, call the customer service department and ask for the preferred pharmacies in your area. Also, check to see what the copays are for using your plan Mail Order service - it can save you money over buying locally.

#5 - use a professional insurance agent that has been trained and certified to offer Medicare health plans and Medicare drug plans. You do not pay for their assistance and buying a plan through an agent costs exactly the same as it does if you enroll online or over the phone. They get paid by the insurance company and the compensation is identical from carrier to carrier thus there is no incentive for the agent to favor one insurance plan over another.

#6 - follow the Medicare Star Ratings. The higher the Star-rating, the better. All companies seek the coveted 5-Star rating but Medicare is stingy on giving these out. Most companies are rated 3.5 Stars and a few earn the 4-Star rating.

#6 - you can make a change to a different Part D plan once a year. The Annual Election Period (AEP) runs from October 15 to December 7 when plan participants can switch plans. And read your Annual Notice of Change (ANOC) document that is mailed out in September. Look for any changes that need your attention.

If your agent hasn't reached out to you by October 15th, call/email or text him/her for a review. If you don't have an agent, contact my office. We always have time to help you find the right plan.

Health Insurance for 2016

The news nationally and here in Washington are filled with stories about health insurance news. Locally, several companies have either left the market or have announced that 2016 may be their last year to offer coverage.

Inside the Health Plan Finder (HPF) there are 136 plans offered for 2016. Only 20 of them are holdovers from last year which means that we have 116 brand new plans. There are some new companies/new players including United Health Care. However, UHC is skittish about remaining in the individual and family market beyond this year. As for the all plans in HPF you must watch for network limitations. Always make sure the doctors you want to see are in the network of the plan you want and can afford.

Outside the HPF the market is shrinking, too. LifeWise Health, spawned by  Premera Blue Cross several years ago has decided to eliminate agents/brokers AND change their open networks to a network that looks a lot like and HMO.

Premera Blue Cross stopped accepting online enrollments in the fall of 2015 and required paper application with proof of residency. Regence BlueShield followed the lead of Premera and also started required proof of residency. Why? Because dishonest people were buying health insurance with expensive pre-existing conditions (pregnancy being one) and then dropping coverage after the big bills were paid by the insurance company. Premera and Regence were hit with millions of dollars of claims.

The last week of January 2016, Premera laid off most of their sales department for individual and family health plans, keeping one person for the west side of WA and one for the east side of the State. This may be a red flag or it may be a sign of tightening their belt to stay viable. Watch closely.

Moda Health came to WA in 2011 as ODS (Oregon Dental Services). Rates were good and the network was very good. Well, Moda has since pulled out of WA and AK. On January 30th the Insurance Department in OR put Moda on the watch list.

This makes for an uncertain future for millions of people. Was the dissolution of the private health insurance market part of the overall plan?

Changes to ACA possible during 114th Congress despite gridlock

Continued gridlock is expected during the 114th Congressional session in

Washington D.C. that began in January. Republicans are expected to propose,

and perhaps pass, significant changes to the Affordable Care Act, only to be

vetoed by President Obama.

However, it’s possible that some changes having bipartisan support may survive a veto, and we could also see some changes to the Affordable Care Act (ACA) made with executive authority. The Supreme Court could even have an impact.

Some potential issues we’re watching closely are:

Changes to the employer mandate.
The law currently requires that employers with 50 or more full time equivalent (FTE) employees offer health care to employees who work at least 30 hours a week or pay a penalty. There is some support for changing that to employees who work 40 hours a week.

Repeal of the medical device tax.

The tax, which went into effect in 2013, was initially passed to help offset the cost of expanding health care coverage to more Americans. There is bipartisan support in Congress for repealing this tax.

Cadillac tax.

The ACA established a tax on employers that offer high cost health benefits—or “Cadillac” plans—to their employees. This tax is due to be implemented in 2018. However, because this type of tax is difficult to operationalize, and with

significant resistance from employers and unions, there is speculation that the

administration could delay or modify its implementation.

King v. Burwell.

The Supreme Court recently agreed to hear a case that challenges whether the federal government can legally provide subsidies through the federally facilitated exchange. Given that Washington runs its own state-based exchange

(Washington Healthplanfinder), the decision in this case won’t directly affect

our market. But it could affect roughly half the states, putting the ACA on

weaker footing nationally.

Of course, none of these changes are certain, and we expect many surprises

as well.

Medicare Health Plans 2015

So what can we expect for 2015? Are Medicare health plans going to remain pretty much the same? Will there be any surprises?

It's early and companies are still in the "file and wait" mode. In other words, rates and plans have been filed with the insurance commissioners but approvals are still pending. My guesses are --

Rates
Monthly premium rates will change. Established plans with reasonable claims experience are likely to keep their rates close to the 2014 prices. Plans new to to the Medicare market often "buy" business with low rates but sometimes get stuck with "the gooey end of the lollipop." Watch for those carriers to play catch-up with higher rates and/or more streamlined benefit plans.

How long will the zero premium plans be with us? For the last three years I have said they cannot be sustained forever. Don't be surprised if your "free" Medicare health plan suddenly starts charging a monthly premium. If they do, they may sweeten the offering. Read the details.

Benefits
Some plans are very "plain Jane" with their benefits package. Others are starting to understand that people appreciate the Silver Sneakers program, preventive dental, vision benefits (exam and hardware with $100 or $125/year toward glasses or contacts) and hearing aid discounts. Don't chase the bells and whistles. Look for solid customer service and a network you can live with.

HMO, PPO or Medigap
Most Medicare Advantage plans are based on the HMO or Health Maintenance Organization platform. PPO or Preferred Provider Organization plans are not as prevalent but are popular with folks that don't like being confined to a limited network. If you qualify, a Medigap policy offers the most freedom and portability. Medigap policies are a bit more expensive but can be set up with no deductibles, no office copays and no coinsurance for you to pay out of pocket.

Go Direct or Use A Professional Agent
By all means, use a professional agent that is licensed, trained and certified to help you find the Medicare health plan that 1) is accepted by your provider (s), 2) meets your needs, 3) covers your prescription medicines and 4) is within your budget. An agent is compensated by the carrier and there is no extra charge or premium to you for using an agent. Do it!

Open Enrollment
If you are currently in a Medicare Advantage plan you are "locked in" until the first of the year. Open enrollment runs from October 15th to December 7th and is the time for you to meet with your agent to see if you are in the right plan or should consider switching to something else. If you have gone direct, this is the time to connect with an agent and have him/her help you.


 

Brief Consumer Guide to Health Law Court Decisions

Topics: Health Reform, States, Politics, Insurance, Marketplace

By Mary Agnes Carey

KHN Staff Writer

Jul 22, 2014

This KHN story can be republished for free. (details)

On Tuesday July 22, 2014 two U.S. appeals courts issued conflicting rulings on a subject that’s important to millions of people:  the availability of subsidies to help purchase coverage under the health-care law.  KHN’s Mary Agnes Carey answers some frequently asked questions about those court decisions and how they impact consumers.
Q: What did the courts decide?
A:  In a blow to the health law, the U.S. Court of Appeals for the District of Columbia Circuit ruled that the health law’s subsidies are available only to individuals in the 14 states and the District of Columbia now operating their own health insurance exchanges.  The federal government now runs the exchanges in 36 states.  Judge Thomas Griffith, writing the majority opinion in the 2-1 decision, said they concluded "that the ACA unambiguously restricts" the subsidies to "exchanges 'established by the state.' "
In a separate ruling, a three-judge panel for the Fourth Circuit Court of Appeals in Richmond, Va., ruled unanimously for the Obama administration, allowing subsidies to be available to residents in all states.  Judge Roger Gregory, writing the opinion, said while the health law is "ambiguous and subject to multiple interpretations," the court decided to uphold the IRS's interpretation of the law that residents of states using the federal exchange are entitled to subsidies.
Q: What was the issue the courts decided on?
A:  The case centers on a brief description in the health law that says subsidies will be available "through an exchange established by the state."

In implementing the law, the Internal Revenue Service (IRS) interpreted the law to allow eligible consumers to receive subsidies to help purchase coverage, regardless of whether they are in an exchange run by their state or by the federal government.
Opponents of the law questioned that interpretation, saying that the law as written clearly directs subsidies to state-based exchanges only.  But proponents– including several lawmakers who helped write it – said lawmakers fully intended that subsidies be offered on all exchanges no matter if they were administered by the feds or state officials.
Q  I don’t know if my state runs its own exchange. Which states do?
A: California, Colorado, Connecticut, Hawaii, Kentucky, Maryland, Massachusetts, Minnesota, Nevada, New York, Oregon, Rhode Island, Vermont, Washington and the District of Columbia all run their own exchanges. 
Idaho and New Mexico intend to set up their own marketplace for the next enrollment period, which begins in November, but used healthcare.gov this year.
Q: I live in a state with a federally run exchange, and I get a subsidy to help me buy coverage. Am I going to lose it?
A: Nothing is happening immediately.  Justice Department officials said Tuesday they plan to seek an en banc review from the D.C. Appeals Court, meaning that the panel’s full contingent of 11 judges would hear the case.  Six of the court’s judges would have to agree for the full panel to review the case. The full panel is dominated by judges appointed by Democrats, 7-4.
Eventually the case could be considered by the Supreme Court, but the current subsidies would likely remain in place until there is a final legal decision on the matter.
"In the meantime, to be clear, people getting premium tax credits should know that nothing has changed; tax credits remain available," said Emily Pierce, deputy director of the Justice Department's office of public affairs.
White House spokesman Josh Earnest said the administration was confident it would prevail. "You don't need a fancy legal degree to understand that Congress intended for every eligible American to have access to tax credits that would lower their health care costs, regardless of whether it was state officials or federal officials who were running the marketplace."
Supporters of the court challenge to the IRS interpretation on subsidies also maintain their case is strong. "The executive branch does not get to rewrite statutes just because it thinks those statutes would work better a certain way," said Michael Cannon, director of health policy studies at the libertarian Cato Institute who championed the subsidy appeals. "If people lose those subsidies it is because the courts have ruled that those subsidies are and always have been unlawful -- that the administration had no authority to administer those in the first place."
Q: Are these the only two court cases?
A: No. There are two other similar cases pending in courts in Oklahoma and Indiana.
Q: If there are legal disputes ongoing about who qualifies to receive a subsidy, do I still have to buy health insurance?
A: Yes.  The law's "individual mandate," which requires most people to purchase health insurance or pay a fine, is still in place.
Q. What if I get my insurance through work?
This decision applies only to policies sold on the online marketplaces. It does not affect work-based insurance, Medicare or Medicaid, regardless of where you live.

What is a "Letter of Entitlement"?

From time to time I am referred to people turning 65 that have not applied for Medicare until just before their intended effective date. It can take two to three weeks for Medicare to send out the card indicating enrollment in Part A and Part B.

All Medicare health plans require the person be enrolled to Medicare Part A and Part B. In fact, the agent/broker must copy the card information onto the enrollment application verbatim.

So, what if the person has not received their card and they want to get their application filed on time so their Medicare health plan begins on the desired date?

You can get a "Letter of Entitlement" for proof of Medicare benefits online. Log into "My Social Security" at http://www.ssa.gov - create a personal account and print off the letter of entitlement without having to wait for the US Postal Service!

The agent/broker can submit a copy of the letter of entitlement with the insurance application. This prompts the insurance company to pend the application and "ping" (check) the MARx (National Eligibility Database) rather than deny the application.

Thus, if you are close to age 65 and are waiting for your Medicare card to arrive in the mail, you can do an end run on the US Postal Service by using the website above to get your own "Letter of Entitlement."

Identity Theft - What will you do?

You read about it all the time. Somebody gets their whole life turned upside down when a thief steals their identity and goes on a buying spree. But did you know there are other kinds of identity theft besides losing cash from your bank account?

Medical Identity Theft
Someone gets enough information about your health insurance coverage to get medical care they need but the bill goes to you! A plastic surgeon tells of a breast augmentation performed on a woman that used a stolen identity and medical insurance information. The expensive surgery was completed and the woman disappeared. Only weeks later was it discovered that the woman that got the bills was not the woman that had the operation.

Criminal Acts In Your Name
A man gets pulled over by police, handcuffed, Mirandized and hauled off to jail. He was innocent but was arrested because someone unknown to him committed a robbery, used his identity when picked up by police and then skipped bail.

Children Are Vulnerable
Almost every child has a Social Security number, including infants. When an identity thief gleans the child's name, birthdate and SSN it's like taking candy from a baby. The years of felony acts and financial damage may not be discovered until the youngster applies for his/her first job or tries to buy a car on credit.

The financial devastation of identity theft is compounded by the emotional stress that goes with such a loss. It's bad enough that you lost all of your savings or were denied a loan on the house you wanted to buy. It's horrible that you were passed over for the job you really wanted because of a poor credit rating you didn't even know you had.

Restoration Process
Restoring your good name is the toughest part. It takes hundreds of hours and sometimes years and thousands of dollars to put your life back the way it was. Do you have the time and knowledge to handle the myriad tasks AND continue to work, raise a family and maintain your sanity?

It's easy to get an identity theft program that notifies you of a breach against your credit. Most identity theft protection plans promise to help you restore your life. But there is a big difference in how IDT plans approach restoration.

One that is advertised heavily on radio does a good job at alerting you of trouble but when the damage is done (and it often does even though an alert is sent by email or text message) the company sends you a kit with information and instructions for you to follow. It's DIY from that point forward.
Good luck.

The IDT plan I have monitors all three credit agencies 24/7 and sends instant alerts when there is a "hit" to my credit file like you'd expect. My IDT plan monitors my online activity and social media for trouble. My IDT plan monitors police records to see if my name pops up. But they do much more.

The IDT plan I use allows me to sign an affidavit that allows Kroll, the global leader in risk mitigation response, to step in and actually do all the legwork to restore my life. Plus, I have unlimited access to attorneys to counsel me on whatever I need in the way of help following a loss of any kind.

How much would you pay for this kind of protection? This kind of identity theft protection and restoration could cost thousands of dollars. But I pay less than $20 per month. And it covers everyone in my household. Interested?