The deadline for seniors to update their Medicare prescription-drug plans is this Saturday, Dec. 7.
By Rose Hoban
Amidst the immense kerfuffle surrounding the rollout of the trouble-plagued insurance website healthcare.gov, many seniors have been wondering what it means for people on Medicare.
“Not much,” said Gina Upchurch, executive director of Senior PharmAssist, a Durham-based nonprofit that helps seniors navigate their options under Medicare.
Upchurch said many Medicare beneficiaries who have come into her agency for help updating their drug benefits have wondered if the troubled rollout of the Affordable Care Act website will make it more difficult to sign up for their Medicare drug benefits.
“People are very confused because they think that they have to go onto the healthcare.gov website to look at their insurance options, and we try to tell them [that] if you are on Medicare, if you have decent employer-sponsored health coverage, you should not be looking at the healthcare.gov marketplaces – you’re good to go as you are,” she said.
Unlike the new healthcare.gov website, Medicare’s drug coverage website has been functioning since late 2005. That website also had trouble when it was launched, but it has been working well for years.
Some seniors have thought they have until the end of the year to re-enroll in drug coverage. But the enrollment period for Medicare Part D benefits ends this Saturday, Dec. 7, Upchurch said. Next year, however, the two enrollment periods will happen simultaneously.
Upchurch emphasized that, as in years before, seniors would do well to comparison shop as they update their drug benefits.
“I always have people who save hundreds, if not thousands, of dollars by changing their benefits,” she said.
Upchurch explained that many, if not most, insurance companies that offer Medicare drug benefits change their plans from year to year. A plan that worked well for a senior one year may not cover a necessary medication the next, or may require a person to change pharmacies in order to save money.
That was the case for Judy Wooden, who manages the medications for her mother. Last year, Wooden’s mother had a Medicare Part D drug plan through Humana. She takes 11 prescriptions, including three inhalers for chronic bronchitis, which together would cost $1,800 a month. For the last year, the three cost her mother only $100 out of pocket in copayments, on top of her monthly premium.
But to Wooden’s dismay, for the coming year Humana has dropped the inhaler drugs her mother needs from their formulary.
“If it were up to Mother, she would not change at all, and then she’d get a shock in January when she finds out that this expensive drug is no longer covered.”
Wooden brandished a 179-page book sent to her mother by Humana with all of this year’s changes to her Part D plan.
“It’s very difficult for a senior to understand all these changes,” she said. “If you didn’t have someone experienced like the people [at Senior PharmAssist] to help out, you’d end up paying more.”
Extra moving parts
Upchurch said that this year seniors will have to make even more decisions in order to find the plan that’s best for them.
She said she’s seen one big change in the Medicare pharmacy plans: the emergence of co-branding between insurance companies and pharmacies.
In the past, consumers would sign up for a particular plan and their insurance company would pay for medications at any pharmacy. But Upchurch said that increasingly more insurers are telling consumers that in order to get lower prices, not only do they have to subscribe to particular plans, they also need to go to certain “preferred” pharmacies.
“The insurance companies are working in cahoots with certain pharmacies and saying that you are going to give us reduced prices and we are going to steer people to your pharmacies,” Upchurch said.
She said that’s a problem because in order to get the best prices, some seniors will be compelled to change their pharmacies. And not only does it force consumers to leave a pharmacy where the pharmacist may know them, but it also means that all of a person’s prescriptions need to move from one to the other.
“All of these transfer of prescriptions have to happen in the beginning of January, and maybe one of the prescriptions doesn’t get transferred, or maybe an old drug gets sent over,” Upchurch said. “It’s confusing and it’s potentially dangerous.”
She said that under Medicare rules, this kind of co-branding is not allowed, but she’s not sure that anyone is checking.
Upchurch said she saw another subtle change to benefits in the form of insurers limiting which pharmacies can fill prescriptions for 60 or 90 days.
“Say I’m trying to help my mother, and I type in the medicines into the website, and it’s an inhaler, and she only picks it up every other month, so I type ‘every other month’ into the computer.
You are going to see some very inappropriate numbers popping up because that insurance company does not allow that pharmacy to dispense a 60-day supply,” Upchurch said. “So it looks like you have to pay the full cost, just because you pick up a medication every other month instead of every month.”
Effects of the Affordable Care Act
Upchurch said the Affordable Care Act has created some changes to Medicare, all of them unrelated to the bungled healthcare.gov rollout.
She said that once consumers end up in the so-called donut hole, <http://blog.medicare.gov/2010/08/09/what-is-the-donut%C2%A0hole/> the gap in drug coverage that kicks in once a drug plan has spent $2,970 on medications, they will pay less for name-brand drugs. And because of the law, Medicare recipients no longer have to make a copayment for visits to the doctor for preventive services.
“However, people are very confused because they think that they have to go onto the healthcare.gov website to look at their insurance options,” Upchurch said. “We try to tell them if you are on Medicare, if you have current Medicaid, if you have decent employer-sponsored health coverage, you should not be looking at the healthcare marketplaces; you’re good to go where you are.”
She said that a number of local large employers – including Duke Energy, Time-Warner Cable, IBM and the State Employees Health Plan – have changed their retirement benefits this year.
That’s happened because while the Affordable Care Act allows large employers to receive a retiree drug subsidy for keeping their retirees on their own drug plans, they will now lose tax breaks they received for doing so.
Not only were they getting money from the federal government, they were also getting a tax write-off for it,” Upchurch said. “So they ended the double-booking of the retiree drug subsidy. A lot of employers decided it was not as advantageous to keep our retirees on their own benefits.”
Many employers decided to instead route retirees through private exchanges to get their Medicare benefits.
The changes affected Howard Matchinger’s sister, a retired state employee who lives in an assisted-living facility in Durham. Matchinger manages her care and her medications.
He said that this year the state health plan was changing her to a Medicare Advantage plan, a type of plan managed by private insurance that covers medical visits as well as medications. One of the plans could cost a bit more for medications but would force Matchinger to change his sister’s mail-order pharmacy.
“It won’t be more than a couple hundred more a year,” Matchinger said. “But last year, we had some problems with the mail-order, and that was a drag because they want you to confirm you’ve hit the donut hole.
But when you call to ask for the confirmation, you can’t call back at that number, you spend time on hold … trivial things, but they’re annoying.”
“Whenever you’re dealing with this stuff, it seems to be you have to be some kind of Talmudic scholar,” he said.