Posts Tagged "Part D prescription drug plan"

Get Help with Medicare Coverage Denials

The United States has a notoriously complex healthcare system, and Medicare is no different.

In the early months of the pandemic, the Medicare Rights Center received a large number of calls to its telephone help line from people over 65 who had suddenly been laid off and lost their employer coverage. Even when there isn’t a crisis, the center’s staff and volunteers answer all manner of questions about Medicare enrollment rules, insurance options, and what to do when an insurance company denies them coverage.

Sarah Murdoch is the center’s director of client services and oversees the helpline. She spoke with Squared Away about the common issues retirees face and how they can address them.

Question: Your helpline fielded 42,000 questions about Medicare in 2020 and 2021. How does that compare to past years?

It’s in that ballpark year to year – around 20,000 questions. But we saw, within that 42,000, a shift in the actual trends.

Throughout the pandemic, particularly in 2020 when there were lockdowns and people were getting laid off left and right, we got a lot of calls from people who unexpectedly had no income. We heard from people who had insurance through their job and that was not an option anymore. Or they were already on Medicare and were trying to figure out how to pay their costs, or they were laid off and had to figure out how to get into Medicare. That has eased up but was a big thing we saw in the beginning of the pandemic.

We also had questions related to benefits for low-income people. We told people who suddenly had zero income about the income requirements for the Medicare Savings Program, Medicaid, and the state pharmaceutical assistance programs – anything that can lessen the hardship.

In 2020 and 2021, nearly a third of the complaints on your helpline were about service denials by insurers that provide Medicare Advantage or Part D drug plans. Start with Advantage plan denials – are they a big issue for retirees?

The Medicare Advantage plans often have doctor and hospital networks, whereas original Medicare doesn’t have networks. People may be denied coverage by an Advantage plan if they have an out-of-network provider. It could also be a denial of a medical service or a prescription medication. We do see it more but it’s hard to tease that out from the fact that more people are just enrolled in Medicare Advantage.

Do Medigap supplements to Medicare have similar issues with denial of coverage?

Medigap is different – the plans are never making their own claim determinations. If something is approved by original Medicare, then Medigap is going to pay for it as long as the retiree has a Medigap plan that has that type of coverage. In the Medicare Advantage policies, however, insurers are making the claims determination. All of the insurance companies have their own claims adjusters making those decisions – as opposed to contractors who process claims for the Medigap plans on behalf of the Centers for Medicare and Medicaid Services. The Medigap insurer isn’t making any decisions as to whether something is covered or not – it has already happened at the government level. …Learn More

Medicare

Enrollment Trends in Medicare Options

Most retirees manage to get by on less than they earned as workers. Yet they devote a much larger percentage of their income to medical care than working people.

To limit their annual spending on care, retirees usually buy some type of insurance policy to help pay the bills Medicare does not cover. But a big shift is under way: the Medigap and employer plans that once dominated are now in decline. Only about a third of retirees have one of these two supplementary arrangements, down from two-thirds in 2002.

Retirees are instead swarming into Medicare Advantage plans  – HMOs run by insurance companies – which doubled enrollment in the past decade to become the most popular form of coverage. A small minority of retirees go without any policy at all, so the only premium they pay is for Medicare Part B’s physician coverage. (The Part A hospital coverage has no premium.) At the same time, the vast majority of retirees today enjoy prescription drug coverage, either through a stand-alone Part D plan or as part of an employer or Advantage plan.

Helen Levy at the University of Michigan digs into what the market changes mean for retirees’ bottom line in recent research funded by the U.S. Social Security Administration.

With fewer employers offering retiree health insurance, new Medicare beneficiaries focus on the tradeoffs between Medigap and Advantage policies. A big reason the Advantage plans have taken off is lower premiums, which are, on average, substantially below the premiums on Medigap plans. Advantage plans’ other appeal is that they frequently cover extra services like dentists and eyeglasses.

Both Advantage and Medigap plans can still leave beneficiaries with high out-of-pocket spending. The federal limit on Advantage plans’ deductibles and copays increased this year to $7,550 per year, though insurers are permitted to reduce this cap. Many Medigap plans do not have out-of-pocket maximums at all. However, these plans tend to give more protection from large medical bills overall.

Just as important to retirees as paying the bills is the risk of being socked with inordinately high spending on hospital and physician care in a bad year. Levy defines this unpredictability as retirees having to shell out more than 10 percent of income out of their pockets, excluding all premiums.

Under this standard, about 23 percent of the retirees in the study with Advantage plans spent more than 10 percent of their income for care – versus 17 percent of Medigap buyers.  About 28 percent of those without any coverage outside of Medicare exceeded the 10-percent threshold. …Learn More