Author Archives: Dianne Savastano

Medicare Open Enrollment — What It Means For You

By Camille Barron

Your mailbox is flooded with literature urging you to sign up for a different Medicare plan. Your insurance company has sent its annual notice, telling you about the changes in your policy for 2021. And your head is spinning, because you don’t know what you should do.

You’re not alone. Medicare can be confusing enough, but every fall the barrage of mixed messages is enough to make anyone feel overwhelmed. Here we will help you sort things out, so you’ll know what’s important and what’s not.

First, a quick refresher on the different components of Medicare and what they each cover:

Component

What it Covers

Part A

Inpatient care, such as in an acute or rehab hospital or in a skilled nursing facility. Hospice services at home

Part B

Outpatient care, including office visits, outpatient surgery, lab work and testing

Part D

Prescription drug coverage

Part C

Known as “Medicare Advantage,” Part C packages Parts A, B and typically D into a single policy

Medicare Supplement

Also known as Medigap, this supplements Parts A and B, which cover just 80% (approximately) of medical costs

During Medicare Open Enrollment, which runs from October 15th to December 7th of every year, people who have a standalone Medicare Prescription Drug plan (PDP) (Part D) or a Medicare Advantage plan (MAP) (Part C)have a chance to change plans for the upcoming year. Common reasons for doing so include:

  • Significant increase in premiums or deductibles
  • Doctors of choice are no longer in-network under a current Medicare Advantage Plan
  • The drug formulary no longer includes certain medication(s)
  • Anticipated better value or more comprehensive coverage

Here are some of the questions we’re often asked during this time.

My medications have changed this year. Should I change my Prescription Drug plan?

If there have been changes to your medications, you should review your coverage to see if your current plan is still the most cost-effective.

You can use the Medicare drug analysis tool on medicare.govto enter your prescriptions and search for the plans in your area. You will see a list of all the options available, including their monthly premiums, deductibles, and estimated drug prices.

Hint: Be sure you pay attention not only to the premium, but to the projected out-of-pocket costs for the year.

My prescriptions haven’t changed. Why should I review my plan for 2021?

Even if your medications remain the same, the coverage and costs for your drugs may be different than last year. It’s important to research this now, before it’s too late. If you don’t, you may find yourself paying a lot more for a prescription than previously. And you’ll have to wait another year to make a change.

Hint: When you conduct your analysis, include competing pharmacies along with your favorite. Pharmacies have different negotiated rates and changing pharmacies may save you money.

I’ve received a notice stating that a new plan from a different company will replace my current one. Is there anything I need to do?

Mergers and acquisitions are common in the insurance industry. If your Prescription Drug coverage is moving to a new plan with a different carrier, don’t assume your costs and coverage will remain the same. It’s important to run a drug analysis to find out what your estimated costs will be under the new plan and whether another option is a better fit for you.

Hint: The notification you receive from the new plan will not encourage you to look elsewhere. You have to do this on your own.

I have a Medicare Advantage policy. What steps should I take to be sure my coverage is still the best for me?

First, as with a standalone Part D plan, it’s worth checking the prescription drug coverage of your existing policy and comparing it to the coverage under a different Medicare Advantage plan.

Second, review the out-of-pocket costs, such as deductibles, copays, and coinsurance, for next year. Some costs may be the same, and others may have increased, or even decreased. Still other plans have added new benefits.

Lastly, review the provider directories to see if your current providers are still in the plan’s network. This is perhaps the most important thing to know if you want to continue seeing your doctors at in-network rates. If your plan is a PPO, you can go outside the plan’s network, but you will pay a higher fee. With an HMO, only in-network providers are covered; if you see a non-network doctor, you will pay the full cost of the visit.

Hint: Just because your provider was in the network last year does not mean he/she is in the network this year. A provider’s status can change, even within a given year.

Should I consider changing my Medigap policy?

Unlike Part D and Medicare Advantage insurance, Medicare Supplement (Medigap) policies are not as restrictive in terms of timing for making changes. Instead of waiting for the Annual Open Enrollment Period, you may apply for a different Medigap plan any time throughout the year. However, after you have passed your Initial Medicare Open Enrollment Period (IEP), you may not be guaranteed acceptance in the new plan.

In all but three states, during your IEP, you’re in a Guaranteed Issue status, meaning that the insurance company must accept your application with no health questions asked. Outside of the IEP, you may apply for a different plan, but will have to answer health questions on the application. Depending on your health history, you could be accepted but at a higher rate or denied coverage altogether if you do not qualify.

Hint: It is rare that we recommend changing your Medigap policy, but it is always worth spending some time evaluating any changes in benefits and cost.

What’s new in 2021?

We follow the industry closely throughout the year, but especially during Open Enrollment, when changes are most often introduced. Here are just a few that we know of so far:

  • Medicare Part B premiums will increase slightly,but the exact amounts will not be finalized by Centers for Medicare and Medicaid Services (CMS) until late 2020. Currently, the standard premium for Medicare Part B is $144.60 per month.
  • Part B Income Related Monthly Adjustment Amounts (IRMAAs) for higher-income earners will increase. The income thresholds that require you to pay an IRMAA may also change for a single person and for those filing joint tax returns.
  • The Part B deductible that is currently $198 per month in 2020 (up from $185 in 2019, and $183 in 2017 and 2018) may increase. The federal government has not yet announced the Part B deductible for 2021, but the numbers from previous years give us a good idea of the ballpark range.
  • The maximum allowable deductible for standard Medicare Part D Prescription Drug Plans (PDP) will be $445 in 2021, up from $435 in 2020. In many plans, the deductible only applies to higher-tier brand name drugs, so if you use generics you may not be subject to a deductible.
  • Medicare beneficiaries with Part D coverage (stand-alone or as part of a Medicare Advantage plan) will have access to low-cost insulin as part of the Part D Senior Savings Model. Approximately one-third of Prescription Drug Plans will offer different types of insulin for a maximum copay of $35.

Summary

Changes are constant and it’s important to separate fact from fiction and avoid taking things at face value.

The only way to know how these changes will impact you is to conduct a comprehensive and detailed analysis of your individual situation, based on how and where you access care, and on the specific prescription drugs you take.

It pays to be an informed consumer, especially when it comes to healthcare!

Insurance Coverage Barriers Matter As Much As Cost

Consider these three recent client examples…

#1. Mr. Smith.

He has significant, chronic medical conditions that require care from a primary care physician and several specialists, one of whom is in a different state than where he lives. He has experienced numerous hospitalizations as a result of his conditions and has a favorite specialized unit in a specific hospital that is very familiar with his case.

In choosing an insurance product, his priority was to have coverage for all these physicians and facilities.

Mr. Smith was considering a Medicare Advantage Plan that was a Health Maintenance Organization (HMO) insurance product. I advised against this. To have coverage under this type of plan, he would be required to stay within a network of physicians and hospitals. Further, he would have to designate a specific primary care physician and obtain referrals to physicians and facilities within the network for specialist care.

Given his care priorities, enrolling in traditional Medicare Parts A and B, and supplementing his coverage with a Medicare Medigap/Supplement Plan along with a separate Medicare Part D Prescription Drug plan, was a much better option, one that would give him more choice and less worry about the future.

#2. Ms. Jones.

She was told that her insurance would not cover an MRI recommended by her physician for an acute back injury. She was in such pain that she decided to pay the $800 out-of-pocket cost for the procedure and appeal the insurer’s decision later. That’s when she contacted us.

Her insurance product denied payment because of the specific clinical criteria they follow to approve such diagnostic testing. The denial stated:

The test should be used when the pain has not improved after six weeks of treatment by your doctor and that treatment should include medications and other forms of therapy such as home exercises and physical therapy. The test was to be used only if it was likely to result in a specific change in treatment and that the change might be related to the need for surgery or a procedure.

As part of the appeal, we asked her physician to write a letter to substantiate his clinical recommendation for an MRI before more conservative treatment was employed.

An alternative for Ms. Jones would have been to wait for the MRI to be approved, following her physician providing up-front, additional clinical documentation to substantiate his recommendation. Such prior approvals are often successful but delays in care result.

#3. Mr. Johnson.

We helped Mr. Johnson overcome numerous delays on the way to being diagnosed with severe sleep apnea. His physicians were optimistic about the good clinical outcomes he might experience from consistent utilization of continuous positive airway pressure therapy (CPAP) to help him breathe more easily when he sleeps.

Unfortunately, his Medicare Advantage Plan only covered a small list of approved medical equipment providers. Of these, the only local one required much additional documentation and was booking appointments 4-6 weeks out. In the end, it took us an additional four months(!) to work through the administrative issues we encountered.

These are just three examples of the kind we experience every day on behalf of our clients. As you can see, the type of plan one chooses plays an important role in determining coverage. Medicare Advantage Plans often appear to be less expensive up front, but the limiting of choice, administrative barriers to accessing care, and out-of-pocket costs as you access that care can be problematic.

Some Practical Suggestions

As much as I wish our healthcare system were easy to manage, it is complicated and something we must learn to live within. With that in mind, here are some ways you can be proactive, taking control where you can and reducing worry.

Anticipate. Every insurance product has administrative barriers. Expect that yours does too.

Learn. Read about your coverage. Call your insurance company before you access care — to verify that providers are in-network, to ensure coverage levels are what they seem, and to fully understand which diagnostic tests and procedures require prior authorization.

Document. Bring necessary documentation with you to your physician practice. Share what you know regarding steps your physician must initiate to assist with authorization for care. During encounters with your physician’s office and insurer, document the date, time, who you spoke with and what they said (this can be very helpful if you experience delays and/or receive inconsistent information and must escalate a concern to a manager).

Identify. In many healthcare practices, there are designated team members who assist with administrative issues and prior authorizations. Identify these people and develop a relationship so that you can follow-up often and directly.

Ask. When buying an insurance product, call the sales department before you purchase. Ask specific questions regarding scenarios you might encounter. For example…

Regarding networks… “I prefer to receive my care from University of MA Medical Center in Worcester MA. If I access care there, will I have coverage? Will that coverage be considered in-network?”

Regarding prior authorization… “I have a condition that might require an orthopedic out-patient surgical procedure in the next year. How will my benefits work?”

Regarding vendors… “I have Type I diabetes and use an insulin pump. What will I need to do to access my supplies and replacement pumps in the future on this plan? Under what benefit will my supplies be paid and how much of the cost will be covered? Are there specific vendors I must use?”

Whew! I know, it’s complicated and it can be frustrating. Fortunately, as the examples and suggestions above illustrate, there are many things you can do to gain control and reduce worry — not to mention time spent and cost!

Recommended Reading: #justdontgetit

#justdontgetit

As I listen to some of the rhetoric about the incidence and the severity of COVID-19 infections in certain demographics, I feel frustrated and find myself constantly saying, “just don’t get infected in the first place.”

Just this past week, Dr. Anthony Fauci said: “From a clinical standpoint, the thing that is the most perplexing to me as a physician is the extraordinary range in spectrum of disease severity.”

I hope these articles about “long-haulers” impact your decision making as we approach the fall and move inside to more confined spaces:

For Some, COVID-19 Symptoms Linger for Months

Long-Haulers are Redefining COVID-19

‘They’re Not Actually Getting Better,’ Says Founder Of COVID-19 Long-Haulers Support Group

Recommended Reading: Health Insurance

These two articles demonstrate how confusion around health insurance is beginning to play out:

Coronavirus survival comes with a $1.1 million, 181-page price tag

I Didn’t Have to Pay a Penny of My $320,000 COVID-19 Hospital Bill. Is That a Good Thing?


This article, “When 511 Epidemiologists Expect to Fly, Hug and Do 18 Other Everyday Activities Again,” helped me in my own decision making about partaking in these activities, now and in the future.

Coping With COVID-19

In previous newsletters, I’ve related personal experiences with my older adult parents as a means of sharing my views on how best to manage a variety of healthcare obstacles and situations. The COVID-19 Pandemic is no exception.

One of the many factors resulting in my decision to cancel a vacation was my need to be within reach (i.e., in the United States) to care for my 84- and 85-year-old parents in the event one or both became ill. I also wanted to be present to meet the needs of clients and their families — supporting, educating and (hopefully!) influencing their behaviors.

Here are some of the things I have been sharing…

Physician visits

We suggested avoiding trips to healthcare organizations whenever possible. We made decisions together to postpone elective appointments and diagnostic testing that could wait.

For those who had urgent problems, we made phone calls to the physician practice in question, to inquire about precautions they were taking. We were so pleased to hear that many of these had already instituted thoughtful and careful steps for protecting patients.

Pharmacies

We recommended avoiding pharmacies but had to be specific about where clients were in the cycle of receiving refills on their medications. Calls to pharmacies and insurance companies were needed to ensure extended supplies of medications where possible.

In some circumstances, clients had someone in their lives who could pick up their medication for them. In other cases, pharmacies were delivering. Those that had to go out, first checked with the pharmacy about picking up via drive through and/or going early, when there were fewer customers.

Greetings

Limiting hand shaking, hugging and kissing, especially with children. We discussed the use of a wave, bowing our heads, or elbow bumps as a means of showing affection.

Appropriate handwashing, how and when

This topic, although being espoused by everyone, had to be elaborated on as most people have never received formal training about how to do this appropriately. Many found the singing of the “Happy Birthday” song twice as an easy guide they could employ.

Everyone laughed when I relayed my sexist attitude about men on this topic. I joked that it was from an observational study of watching the most important men in my life — my husband, father, and grandson — that I have concluded that men don’t wash their hands adequately. A little humor always helps!

Not touching one’s face

This topic was a hard one as everyone reacted with how difficult it is to do. Raising our consciousness was a place to start. My parents have begun reminding each other when they observe this behavior, with the hope they can train themselves to resist the urge.

Staying home

This was a tough conversation with my parents, particularly regarding church attendance. They thought it would be okay because they attend with friends and know everyone who sits near them. I struggled with their desire to attend and to respect their choices.

At the same time, I know that how well you are acquainted with someone has little to do with their potential for infection. In the end, being able to point out that Catholic Bishops all over the country were providing dispensation from attending mass came in handy!

Social Isolation

Many articles and television segments have been devoted to the potential for loneliness as a result of social distancing. I always encourage my mom to be more social, and now I am telling her to do the opposite!

Yes, there are other ways to stay connected. But we must all be conscious of the limitations many of the newer technologies may pose for the less tech-savvy older adults among us. I am fortunate that my parents have each other, and we created a plan to speak twice each day by phone.

Final Thoughts

We must plan to manage the care of our loved ones should they require hospitalization, particularly if they are not local to you. I refer you to previous newsletters — here and here — that describe how to prepare, by having a HIPAA compliant medical release form on hand, along with a Personal Healthcare File.

Unfortunately, we cannot rely on medical record systems to interact with each other, so we must plan to be the conduit of information about our loved ones, representing their baseline level of health and functional abilities. I highly suggest that you take the time to organize your information, just in case.

So much has changed in just the past 24 hours since I sat down to write this newsletter. Please care for yourself, so that you are able to care for others. And, as you reach out to care for the older adults in your life, remember to listen to what they are thinking first and plan from there, constantly adjusting to the crisis at hand.