Archive for the ‘Pharmacy’ Category

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Turning 65 years old and enrolling in Medicare seem to be a pleasant change. Getting rid of the expensive health insurance is a welcome transformation, until one is faced with all the choices they have to make.

Medicare has parts which are A, B, C, and D.

Part A covers hospitalization, qualified nursing home rehabilitations, and mental health hospitalizations. Part B covers outpatient hospital services,  doctor visits, diagnostic services, such as blood tests, x-ray, MRIs, CT Scans, injectable drugs, durable medical equipment, etc. Part D is a drug plan for pharmacy based prescriptions. Medicare part C is an exchange of all of the above to convert Medicare into a “private insurance”.

Medicare does not pay for medical care in full; therefore there is a need for a supplemental plan. So, to further confuse matters those supplemental plans comes lettered as well. Presently those letters run from A to N. Some counties are skipping some letters in between.

Moreover, through the Medicare program there are about 40 prescription plans available in each state. Prices, coverage, administrative rules, deductibles, co-pays, and cost shares vary between these plans. Medicare made every effort to streamline and explain all these details, but unfortunately there are so many rules and details, that most people get lost in the information overload.

We are at MedBillsAssist explain all parts of Medicare and help you chose the best possible solution for your specific needs.

Pushing through this monstrous legislation called the Patient Protection and Affordability Care Act (PPACA) was just a beginning of slowly escalating problems with implementation of gradually coming to effect provisions.

We did really well eliminating pre-existing condition limits for children, and everyone liked the young adult coverage extension to age 26, under the parents large group policies.

We are hitting a bump on the road with implementation of the medical loss ratio, which is now in the books and forcing the insurance companies to pay out about 80% of collected premiums on claim expenses. Just like any other business, insurance companies have regular business expenses they have to account for. So the battle was brewing for a while to decide which expenses can be allocated under the general umbrella of claims expense.

The new major outcry is now originating from religious groups. The law added a significant change which makes women health and reproduction along with planned birth control part of a category of preventive care.

In the past religion based institutions were exempted from covering birth control and coverage for reproductive services, other than child birth. The PPACA now requires faith based large organizations, such as hospitals and universities to cover birth control as part of the basic preventive care. (Small churches with only faith based employees are still exempt.)

There is nothing in this law that force women to use birth control, it is only an option to do so. My insurance covers surgery for broken leg, yet I don’t go and break my leg, just because it is covered. This law simply gives women the option to use family planning, fertilization treatments and birth control if they so desire.

Why should this option denied for women who do not agree with the church dogma, or not even catholic, just because their employer has a religious objection to it?

These same religious organizations receive significant federal funding; yet want to be excluded from public healthcare policy. It would seem fair to me to obey federal policy in return for federal funding.

The time frame to change current Medicare plans has been moved up. This year, open enrollment started on October 15 and ends on December 7.
Actual changes will take effect, as usual, on January 1.
This is the time to review cost, coverage and convenience. It is time to consider a return to traditional Medicare or to check out if there is a Medicare Advantage plan that may offer better benefit options.
It is also time to change prescription plans. It is the perfect time to review all letters arriving from the present drug plan. There may be changes in the formulary for next year, which can adversely effect your bottom line. As always information is available at www.medicare.gov
Of course people that are satisfied with their current choices don’t have to make any changes.

Below are some highlights in phase two of the Health Care Reform Bill.

This is the year when our tax codes are going through significant changes driven by the health care law.  Overall, health care is getting more regulated, therefore it is forcing businesses, health care providers and insurance companies to spend more money on administration.  There are a lot of plans that are studying and “advising” on how to make health care better.  Sadly, those groups and advisory bodies should have been created prior to the enactment of this law.

• Minimum Medical Loss Ratio

Health plans, including grandfathered plans, must report on the share of premium dollars spent on medical care and provide consumer rebates for excessive medical loss ratios.

• Consumer Protection

Prohibits individual and group health plans from placing lifetime limits on the dollar value of coverage as well as rescinding coverage except in cases of fraud.  Annual limits are still in effect until 2014.  The provision also prohibits plans from denying children coverage based on pre-existing medical conditions.

• Standardizing the Definition of Qualified Medical Expense

Match the definition of qualified medical expenses for HSAs, FSAs and HRAs to the definition used by the IRS itemized deduction.  Over-the-counter medicine will now only be considered as medical expense of accompanied by a doctor’s prescription.

• Reporting Health Coverage Costs on Form W-2

Requires employers to disclose the value of the benefit provided by the employer for each employee’s health insurance coverage on the employee’s annual Form W-2.

• Creating Simple Cafeteria Plans

Creates a Simple Cafeteria Plan to provide a vehicle through which small businesses can provide tax‐free benefits to their employees.

• Appealing Health Plan Decisions

Appoints the right to appeal medical claim and/or policy decisions made by any health plan and the right to appeal decisions made by the health plan to an outside, independent decision-maker, no matter what state a person lives in or what type of health coverage a person may have. This includes, for the first time, new self-funded plans.

Read the rest of this entry »

Creating new programs to administer more and pay less is an ever growing trend with insurance companies. United Healthcare new specialty medication management program is just that; more hoops to jump for less.

Industry insiders long known that the federal Medicare program is a leader in the creation of more administration and less payment.  Blue Cross and Blue Shield usually follow closely, and then the rest of the pack (insurance companies in general).

Now United Healthcare seems to be taking the leading role of creating an additional program without benefits to its members.  The Specialty Pharmacy Program is designated to put more stops in prescription utilization for high cost drugs. New and renewal members will be forced to obtain certain medications from a participating specialty pharmacy to receive in network coverage. Furthermore this policy eliminates the previous 90 day supply benefits, both as a discount and convenience. Members will be forced to renew prescriptions each month and pay the 30 day co pays.

Typical of insurance policies, coverage by out of network pharmacy is not clearly defined. No one can tell until they visit a local pharmacy.

Last Sunday was one of those days; it rained all day, the air was cold. Unfortunately, we run into an unexpected medical problem. A visit to the local urgent care center was in order. The short medical trip resulted in two prescriptions.

Going to the local CVS drug store did not appeal to either of us, so I suggested trying something new. I called Hope Street Pharmacy and asked if they have these medications available. A friendly person on the other end asked me to fax the prescription and they will let me know. With the fax, I included our insurance card along with a request for delivery. In about 15 minutes, I received a phone call; asking the usual questions, such as allergy for medications, etc. She also told me that the driver would be leaving soon. About a half hour later, we had the medicines at our doorstep. Altogether, it took less time than going to CVS, waiting for the fill and coming back home. Our insurance picked up the cost, just as it would have paid at CVS or any other big chain pharmacies.

I am sharing this story for one reason only. If you live in Greenwich, Stamford, Darien neighborhoods you have an option to use your friendly neighborhood pharmacy, instead of going to one of the big and impersonal chain stores. You will have friendly service, and option for delivery and so much more. Hope Street Pharmacy also blister package or daily/weekly/monthly dose package medications per special request. They also provide compounding and many other special services to improve the life of others.