Archive for the ‘Prescription Benefits’ 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.

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Many health care reform provisions went into effect on September 23, but as with any new law some will start right away, and others will slowly be implemented over time.

Small business tax credits for companies with fewer than 25 employees are now in effect. Provisions to rescind policies are banned. People now are afforded federally protected appeals rights.
Some provisions are not welcome by the insurance industry and are being challenged in their own way. For example, insurers are now prohibited from denying coverage for children with pre-existing medical conditions. Insurance companies have responded by eliminating children’s policies in several states.
The ugly duckling, known as the medical loss ratio, is being legislated at 80% for small groups and 85% for large groups with a mandated rebate if the insurer fails to meet these ratios. Insurance companies have responded by reclassifying certain expenses as medical services.
Although other provisions are already in effect, such as dependent coverage for adult children up to age 26 for all policies, and requiring qualified health plans to provide minimum coverage for certain preventive services without cost sharing, these will only start when policies are renewed. In many instances, this will be in January 2011.
Interstate insurance exchange programs should already be in place, but they are running far behind schedule. The federal government does not know how to run them and state programs are so different from each other that most states have decided not to run their own.

Most states estimate serious financial shortfalls in this program; therefore they are hesitant to get it started.

Medicare changes are taking effect as well, such as cuts in all hospital payment rates, payment reduction to Medicare Advantage plans and a significant start in eliminating the prescription coverage gap.

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Nobody wants to get a $4,000 medical bill; especially if they haven’t been in a hospital for years.  But it can happen to anyone and according to a recent survey by the Ponemon Institute it already happened to 5.8% adults in America. They have been a victim of medical identity theft, costing an average of $20,160.  The human cost is even higher.
Patients whose medical identities are stolen face serious drawn out effects. Fraudulent health care events can leave erroneous data in medical records. This erroneous information, such as information about tests, diagnoses and procedures, can greatly affect future health care and insurance coverage along with costs. Patients are often unaware of medical identity theft until a medical bill or a collection notice exposes the problem. Then, the burden of proof is with the patient and it is difficult to get the patient’s legitimate medical records cleaned up. The consequences can be life threatening and can lead to serious medical treatment errors and fatalities.
We all are at risk. Our personal information is sprinkled all over in the globe.  US companies hire subcontractors in other nations to provide customer service; data processing and many other functions. Your and my medical claims data can be accessed in the Philippines, because labor is cheaper there.  But even if we consider staying within the border of our nation we can all remember stories about stolen government laptops, lost backup tapes.
Last year CVS, the pharmacy giant, was fined $2.25 million for failing to protect sensitive financial and medical information of its customers and employees.
Just recently 12,000 Medicare enrollees had their protected health information compromised by a simple filing cabinet donation gone wrong.  Blue Cross & Blue Shield of Rhode Island donated a filing cabinet to a nonprofit organization without first removing surveys that contained Medicare PHI (Protected Health Information). 
While all these stories are awful I believe the real danger is still lies with individuals who work for doctors, clinics and hospitals.  They steal patient records in minutes by downloading information on a flash drive and sell it on a black market.  This could be an unhappy employee or someone recently hired to take a position simply to purloin information.
The only real protection is keeping a close eye on your medial identity.  Check your insurance Explanation of Benefits, look online and make sure that services billed are actually received, ask your insurance company to send you an annual statement for all your medical services.

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.