Bad Part D Choices Can Lead to Extra Expenses for Seniors on Medicare
Tis the season for anyone on Medicare to decide if they want to make any changes to their Medicare Part D plan beginning with the New Year and the ads are everywhere.
There are ads from pharmacies, offering assistance choosing a Part D plan, and ads from Part D providers encouraging people to choose their option.
Having observed some of these plans in action last spring as they came into effect, I have a few words of caution for anyone selecting or changing their Medicare Part D plan. Part D is the Medicare prescription drug program that has been highly touted as a boon for those on Medicare, but in reality is not as good as it could be.
In Illinois, many people who are now covered by Medicare Part D were once covered by an Illinois state program called Circuit Breaker. The Circuit Breaker program helped those low-income seniors without a Medicare supplement insurance to get prescription drugs at a reasonable cost. Sure, there were co-pays, but most were $10 to $15.
When the federal government began offering the Medicare Part D option, p
eople who were receiving Circuit Breaker were notified that the state would help pay their premium for enrollment in a Part D program. That relieves the state of the burden of paying for these medications and puts it squarely on the insurance companies that offer Part D policies.
The problem is that someone forgot to do their research and I have lost count of the number of senior citizens that I have seen who have to change their medication, or pay a substantially larger co-pay due to the program that was supposed to be a boon.
Because it is the field I worked in, most of my experience is with co-pays for eye medications. Most often, glaucoma drops. These drops are used daily, or sometimes more often, to control the pressure in the eye and stop deterioration of the optic nerve. In short, they keep people from going blind.
People with advanced glaucoma sometimes take more than one drop a day and most of them have a base cost of about $70, sometimes more. Under the circuit breaker program, many of the people were eligible to pay a single co-pay for a three-month supply of the drug, effectively paying $5 a month to save their eyesight.
Once the new Medicare Part D program was in effect, the mail-order three-month supply option was eliminated for many people. In addition, each of the insurance companies that provides Medicare Part D plans has a different list of preferred medications. If the eye drop a patient is on is not a preferred drug, they have the option of changing drops or paying co-pays that range up to $50. In short, the Medicare Part D program was suddenly costing people as much as ten times what they had been paying before.
Another problem with the program is that it made few exceptions for people who could not take a preferred drug. In many cases, the preferred glaucoma drop was a beta-blocker which people who have had chronic lung problems cannot take. In some instances, the doctor could request that the patient be allowed to continue on a different medication, but in many instances, the requests were denied or took months to complete during which the patients were often left without medication or simply paying for them out of pocket. So much for Part D saving them money!
And, the biggest offense of all of the Part D providers was a sneaky little trick some played, offering Medicare Part D for free to people who had Medicare Part B. The only catch: You had to switch your Part B from being provided by the federal government to a private insurance company. Medicare Part B is the Medicare that pays for doctor visits and the person who has the coverage pays for it through a monthly deduction from their social security.
It sounded like a great deal. Instead of paying for both Part B and Part D, they could get Part D for free simply by switching who paid their Part B claims. Like almost everything that sounds too good to be true, it was.
What insurance companies forgot/neglected to tell them was that their Part B coverage would change from what they were used to and what they had been provided by the federal government. With the federally overseen policy, Part B had a deductible of about $200 payable once a year and then it paid 80 percent of the patient's doctor's bills, provided that the bills were for services deemed medically necessary by the government overseers. There were no off-the-top co-pays.
Under at least one of the plans issued by a private insurance company, things changed a lot. The plan was a health maintenance organization (HMO), so patients had to see once of the plan's doctors or be charged even higher, out-of-network deductibles or have their claims simply denied. Patients had to pay a $30 co-pay for every office visit, before the company paid a dime. And, they still had an annual deductible of about $200.
In our region, it also meant that many of the area's largest clinics were not part of the HMO and had no intention of becoming part of it, so patients were faced with the possibility of having to find a new doctor or pay increased fees for their doctor visits.
The insurance company made up for "giving away" the prescription drug plan by substantially cutting the benefits under Part B, the Medicare that most patients use most often. Hospital and nursing home charges fall to Part A, but Part B is the most commonly used formed of Medicare.
In short, if you or someone you care about is considering a Part D Medicare program for the first time or thinking of switching their Part D provider, they need to do some research first.
1) Find out if the company covers the drugs you need on a regular basis you are changing to. Most of the Medicare Part D providers have links from the Medicare website. If you cannot find the answer at the website, call and get a specific list, called a drug formulary, from the insurance provider. These do change periodically, but at least have one in hand before deciding to make a switch.
2) Ask if accepting the Part D provider comes with any strings attached, like having to change your Part B provider as well. If it does, get a specific list of deductibles, co-pays, and the standard coverages of the plan.
3) Find out what the co-pays are for the plan. Most prescription insurances have a three-tiered co-pay system. The lowest co-pay is for generic drugs, then for name brand drugs that are part of the insurance company's formulary and then the highest co-pays are for drugs that are considered non-formulary. This often applies to name brands drugs that have not been on the market for very long. Occasionally, insurance companies will also simply refuse to pay for drugs that they consider too new or experimental.
4) Find out if you already have prescription drug benefits that are better than Medicare Part D. Some insurances, either private plans an individual has purchased or insurance they receive as a retirement benefit, have prescription drug plans included in them. Be sure to find out how your existing plan works with Medicare Part D and if you even need to be paying for Part D at all.
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