No Surprises Here
I'm giving a presentation on the Medicare Part D to a group next week, so I thought I should go to the Medicare Prescription Drug Plan Finder and give the software a test flight.
Choosing a plan was supposed to be simple: just plug your current medications into the Medicare website and the computer will tell you the plans best suited for you to buy.
I am depressingly healthy, so I called up a friend with high medication costs. In my zip code, which is how the search begins, there are 47 free standing prescription plans available and 19 Medicare Advantage Plans (managed care). Each plan needs to have its formulary searched, the out of pocket costs uncovered, as well as the monthly premium. Each plan also makes suggestions on how to lower costs, primarily through switching to generics. Each listing also notes that there may be additional hoops that must be jumped through, such as pre-certification, limits on quantity, or step therapy requirements.
What does that mean, I wondered? I mean, I know what pre-cert means, and step therapy - but what does a quantity limit mean? Is that a lifetime limit? Do they perhaps limit the number to 15 pills each month and expect them to be split?
So I called one of the insurers, and guess what - they don't know either! But they will tell you that if you sign up, they'll send you the plan literature so you can find out!
The complexity of the information plus the huge variations in costs was pretty discouraging: the lowest premium was $4.10; the highest $85.02. The total out-of-pocket costs ranged from $4255 to $10,101. The differences seemed to be based primarily on formulary, but the only way I thought I could be really sure would be to print out all 47 formulary and plan details, and do a side by side comparison.
So then I looked at the 19 Advantage plans. This was even more confusing. The comparison of these plans used precisely the same interface: out of pocket expenses ranged from $4440 - $9736, premiums varying from $0 to over $100/month. But some plans had only a health premium, and some had only a medication premium, some had no premium, and some had both. Different formularies here, too.
To compare these was even more difficult - not only would you have to print out the drug benefit details from the Medicare pages, but then to be a truly informed shopper you would have to do a separate search of each plan you were interested in off the CMS site. In other words, there were no details of any of these HMO plans - no lists of providers or hospitals, no definitions or exclusions; not even the information whether they were an HMO, or a PPO, an EPO or some hybrid. And what does PPO III mean? Does that mean the network is bigger or smaller than the PPO I? Is the reimbursement to the physician bigger, smaller, or the same?
The best part, of course, is that all that information on the Medicare site is not guaranteed. It could be correct, but you can't hold the government responsible if it's not. Once you've made your choice you are locked on for a year (except for this year - you can change once), but the Plan can change every week!
CMS is telling us all that this won't happen, and it probably won't. Drug prices are more stable than that. But they could, as my health plan just did, drop your medication from its formulary for no discernable reason, or place your medication under a pre-certification restriction. They can change the premiums and the co-payments. I expect that after a few months most plans will begin to make some adjustments.
Of course, you could also need to add a medication or two not on your formulary when you first signed up, and you'd just be SOL.
I cannot imagine why the the good ol' New York Times headlined its editorial yesterday, A Good but Puzzling Drug Benefit.
Lin
Cross Posted at http://www.signalhealth.com
Choosing a plan was supposed to be simple: just plug your current medications into the Medicare website and the computer will tell you the plans best suited for you to buy.
I am depressingly healthy, so I called up a friend with high medication costs. In my zip code, which is how the search begins, there are 47 free standing prescription plans available and 19 Medicare Advantage Plans (managed care). Each plan needs to have its formulary searched, the out of pocket costs uncovered, as well as the monthly premium. Each plan also makes suggestions on how to lower costs, primarily through switching to generics. Each listing also notes that there may be additional hoops that must be jumped through, such as pre-certification, limits on quantity, or step therapy requirements.
What does that mean, I wondered? I mean, I know what pre-cert means, and step therapy - but what does a quantity limit mean? Is that a lifetime limit? Do they perhaps limit the number to 15 pills each month and expect them to be split?
So I called one of the insurers, and guess what - they don't know either! But they will tell you that if you sign up, they'll send you the plan literature so you can find out!
The complexity of the information plus the huge variations in costs was pretty discouraging: the lowest premium was $4.10; the highest $85.02. The total out-of-pocket costs ranged from $4255 to $10,101. The differences seemed to be based primarily on formulary, but the only way I thought I could be really sure would be to print out all 47 formulary and plan details, and do a side by side comparison.
So then I looked at the 19 Advantage plans. This was even more confusing. The comparison of these plans used precisely the same interface: out of pocket expenses ranged from $4440 - $9736, premiums varying from $0 to over $100/month. But some plans had only a health premium, and some had only a medication premium, some had no premium, and some had both. Different formularies here, too.
To compare these was even more difficult - not only would you have to print out the drug benefit details from the Medicare pages, but then to be a truly informed shopper you would have to do a separate search of each plan you were interested in off the CMS site. In other words, there were no details of any of these HMO plans - no lists of providers or hospitals, no definitions or exclusions; not even the information whether they were an HMO, or a PPO, an EPO or some hybrid. And what does PPO III mean? Does that mean the network is bigger or smaller than the PPO I? Is the reimbursement to the physician bigger, smaller, or the same?
The best part, of course, is that all that information on the Medicare site is not guaranteed. It could be correct, but you can't hold the government responsible if it's not. Once you've made your choice you are locked on for a year (except for this year - you can change once), but the Plan can change every week!
CMS is telling us all that this won't happen, and it probably won't. Drug prices are more stable than that. But they could, as my health plan just did, drop your medication from its formulary for no discernable reason, or place your medication under a pre-certification restriction. They can change the premiums and the co-payments. I expect that after a few months most plans will begin to make some adjustments.
Of course, you could also need to add a medication or two not on your formulary when you first signed up, and you'd just be SOL.
I cannot imagine why the the good ol' New York Times headlined its editorial yesterday, A Good but Puzzling Drug Benefit.
Lin
Cross Posted at http://www.signalhealth.com
posted by
at 6:02 PM
1 Comments:
Lin,
Health Advocacy grad Lois Steinberg directs the Westchester Medicare Rights Center programs, and a current student, Shawna Irish, is a Medicare Rights Center fellow who is, as we speak, developing and coordinating a counseling service for residents in the County who will be making Medicare Part D decisions.
I sat down with Lois and Shawna the other day to find out how things were going and learned much of what you have confirmed in your blog. Just wild!
Lois says that seniors at their information sessions are saying, "Who did this? Why didn't we know?" The sad part is that as advocates we did know and we still couldn't stop the juggernaut. The memory of AARP selling its membership down the river at the zero hour will be one of the highlights of the misuse of advocacy.
Thanks for sharing your experience. It's pretty frightening when a professional advocate who specializes in health insurance advocacy tells it like it is.
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