Editor’s Note: Open enrollment for Medicare is here – until Dec. 7. To help readers navigate this period and their other Medicare decisions, Making Sen$e has introduced a new column, “Ask Phil, the Medicare Maven.”
Journalist Philip Moeller, who writes widely on health and retirement, provided an overview of what he calls “health care’s Groundhog Day” when enrollment opened last week, and he returns this week to address Medicare’s prescription program.
He’ll continue to keep you informed on this page, and he’s taking your questions.
By now, you’ve probably heard that it’s Medicare open enrollment season. Is there some overarching truth that can guide you, and more than 45 million other 65-and-older Americans, through this rodent maze of programs and rules to make optimal use of Medicare’s truly amazing range of benefits?
Yes, never getting sick is a nice thought. But it’s probably not an option.
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So, strap on your body armor and try to accept that Medicare is the battlefield of old-age wellness. It’s the place where the trenches may not move at all while the combatants whale on each other using billing codes, diagnostic sleight of hand and mind-numbing bureaucratic hand-to-hand fighting.
During open enrollment season, which extends until Dec. 7 (a perfect end date for such bellicose imagery), you actually will have the chance to do battle with Medicare insurers and possibly defeat them. Victory could mean better coverage and services, often at lower cost, with a longer and higher-quality life to boot.
Today’s battle theater is Medicare Part D, the prescription drug program. Upward of 40 million people have Part D drug plans, either as part of their private Medicare Advantage program or as stand-alone programs that may be combined with basic Medicare (Parts A and B, which cover qualifying hospital, physician, outpatient and medical equipment expenses).
Like a flu shot, reviewing health insurance choices is an unpleasant but necessary duty. “I know it’s complicated and you don’t want to do it,” counsels Diane Lifsey with the National Committee to Preserve Social Security and Medicare. But if people would take the time and get the help, they would find it worth their while, she adds.
Faced with so much information to digest, people are especially susceptible to the encouraging bromides of private Medicare insurers, five of which dominate the Part D market – Aetna, CVS Caremark, Express Scripts, Humana and UnitedHealth. Why do all this work? Just renew with us and go back to your wonderful retirement life.
But of course, retirement life can be pretty stressful, and one of the reasons is the high and unpredictable price of health care. You’d think that having Medicare would help here, and it can. But you need to know how to use it or, odds are, you will get shafted.
There are no blockbuster headlines that retirees need to consider for Part D plans in 2015, says Tricia Neuman, a senior vice president at the Kaiser Family Foundation who heads its Medicare policy work. But there are still plenty of changes to plans that they need to know about.
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More and more drug plans, for example, are linking up with big pharmacy networks, Neuman notes. And while people may be able to get lower prices on prescriptions from these networks, they may not be comfortable dealing with mail-order prescriptions. Likewise, even if networks have physical pharmacies, their locations may not be convenient. Going to a local and trusted but out-of-network pharmacy, meanwhile, could result in much higher prescription prices. So what’s a person to do? Find out about such matters before signing up for a plan.
Part D plans may move in or out of lots of geographic markets in a new plan year. “We’re seeing a pretty significant consolidation,” says Christine Harhaj, a senior manager at Avalere Health, which provides health consulting services and studies health insurance plans and trends. Plans are similar across different jurisdictions but insurers make adjustments because of local market conditions, including relationships with local health care providers and competitive factors.
In 2015, there will be 1,001 distinct Part D plans offered in the 34 geographic service areas dictated by Medicare. That’s down nearly 7 percent from 1,070 during the 2014 plan year, Harhaj says, but people will be able to pick from 24 to 33 plans wherever they live. New England markets have seen the heaviest plan withdrawals by insurers and will offer the fewest plans in 2015.
Besides having to choose from fewer plans, Medicare recipients will likely also feel the pinch of higher co-pays, says Harhaj, especially as plans transition from flat dollar co-pays to percentage co-insurance payments. That twinge you feel is in your wallet.
Drug plans may also make lots of changes in the line-up of drugs they offer – called a formulary — and in the charges people have to pay. Most plans offer four to six different pricing tiers for different drugs, with prices and co-pays rising in higher tiers, which contain the most expensive brand-name drugs. Plans have to cover a variety of medical needs but do not have to offer every drug that does so. And prices can vary among different plans. So it’s important to find out how your prescription drugs are covered by the Part D plans available where you live.
The fastest way to do this is online, using Medicare’s Plan Finder. It is not easy to use but gets generally high marks from independent experts. Before trying to use this tool, you should first have a list of your prescription medications, including the dosage amounts and frequencies for each drug you take.
If you are prescribed a brand-name drug by your doctor, you should also know its generic equivalent (if there is one). Plans generally will require you to take a lower-cost generic if available. You can normally continue taking the brand-name version if your doctor prefers it. But you will have to pay more for it. Plans charge more for brand-name drugs – often a lot more. There’s that twinge again.
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Once you’ve gathered all this information, you can tackle the Plan Finder. I did, and somehow, managed to live to tell the tale. The tool may save you money and help you find the plan that best meets your needs, but you’re going to have to work through it to earn those benefits. I walk you through it here.
However, if you are not comfortable doing this on your own, you can call Medicare at 1-800-633-4227 (1-800-MEDICARE); the TTY number is 1-877-486-2048. You also can request free one-on-one Medicare counseling from the State Health Insurance Assistance (SHIP) Program. SHIP offers localized help because Medicare plans and rules vary by locale. There’s an online form to locate a nearby counselor.
Lots of people have Part D plans that are combined with basic Medicare Parts A and B coverage. Many people also use Medigap policies to fill coverage gaps in Medicare. Medigap benefits should, therefore, be considered in evaluating the Medicare drug plan that makes sense to you. Lastly, more than 15 million people get their prescription drug coverage as part of a broader Medicare Advantage policy. Next week’s column will be about 2015 changes and trends in those plans.