©MedBillsAssist™ Blogs

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.

Medicare Premiums for 2010:

Part A: (Hospital Insurance) Premium

Most people do not pay a monthly Part A premium because they or a spouse has 40 or more quarters of Medicare-covered employment.
For those who have not earned Medicare part A, by working 10 years, monthly fees applies as follows:
•The Part A premium is $254.00 per month for people having 30-39 quarters of Medicare-covered employment.
•The Part A premium is $461.00 per month for people who are not otherwise eligible for premium-free hospital insurance and have less than 30 quarters of Medicare-covered employment.

Part B: (Medical Insurance) Premium

Most beneficiaries will continue to pay the same $96.40 premium amount in 2010. Beneficiaries who currently have the Social Security Administration (SSA) withhold their Part B premium and have incomes of $85,000 or less (or $170,000 or less for joint filers) will not have an increase in their Part B premium in 2010.
For all others, the standard Medicare Part B monthly premium will be $110.50 in 2010, which is a 15% increase over the 2009 premium. If your income is above $85,000 (single) or $170,000 (married couple), then your Medicare Part B premium may be higher than $110.50 per month.

The day before Thanksgiving I received a call from Barbara. She has been enrolled on Medicare part A for years. She recently lost her job and elected COBRA, continuation of medical insurance coverage, from her former employer. This recent event triggered a letter from the Human Resources of her former employer. The letter is written in a confusing language of insurance and Medicare. It is difficult to decipher, unless a person knows the rules, and understands the connection between employer based medical insurance and Medicare.

The first relevant rule is the election of COBRA benefits that makes Medicare primary over the COBRA based medical insurance. The second rule, in her situation, is the special enrollment period.

Barbara had to contend with her special enrollment, along with a crazy New York insurance law that allows insurance companies to pay only 20% of Medicare fee schedule, when seeking medical care. If she decide not to enroll on Medicare part B, she will be responsible for 80% of the same Medicare fee schedule. (Medicare fee schedule is based on the government complex calculation for medical services.)

Medicare’s enrollment is administered by the Social Security office, therefore Barbara called the office to request enrollment on Medicare part B. She was told that they could send her the forms, but they have to be filled out and postmarked no later than November 30. They do not send anything by FedEx or UPS. At the suggestion of the telephone helper, she wrote a letter to SSA stating that she wanted to get Medicare part B. Then, she went to deliver it personally and waited about an hour until her number was called. Barbara spoke to a person who insisted that she get a form, providing exact date of termination, signed by her former employer. She had spent 1.5 hours in the SS office, and then she sent the form by UPS overnight to her former employer with a return paid UPS label addressed to her. The clerk explained that he needs this date to know when to start Medicare part B. Her full Medicare coverage may start on November 1 or December 1. The Social Security clerk gave a date stamp on Barbara’s letter with his signature, which she has to bring back with the HR letter on Monday.

I hope Barbara will have her letter; therefore, she will have Medicare part B next month.

I additionally hope that at some point our federal lawmakers will step back and see the monstrosity, and unnecessary burden they are creating for people whom already earned Medicare enrollment.

While our postings of events are authentic, we always use fictitious names to protect the identity of our clients.

There are four Medicare enrollment periods. These enrollment periods are confusing and overlapping. A beneficiary who does not act carefully may lose needed Part B or Part D coverage.

Annual Coordinated Election Period (AEP)

The Annual Coordinated Election Period runs from November 15 through December 31 each year.  During this time, people whom are already enrolled on Medicare, may change prescription drug plans, change Medicare Advantage plans, return to original Medicare, or enroll in a Medicare Advantage plan for the first time.  Enrollment changes take effect on January 1.

General Enrollment Period (GEP) 

Medicare beneficiaries who did not enroll in Part B when they first became eligible, usually at age 65, for Medicare may elect Part B coverage during the General Enrollment Period. This runs from January 1 through March 31 each year.  Enrollment changes take effect on July 1 of the same year.

Beneficiaries who delay enrollment in Part B is assessed a late enrollment penalty on their Part B premium.  The penalty is 10% for each full year of delayed enrollment for as long as the beneficiary remains covered under Part B. 

Part B enrollment during the General Enrollment Period also has a Special Enrollment Period (SEP) for Part D.  From April through June of each year a new Part B enrollee may make one election to join a Part D plan.  This enrollment also enables beneficiaries who elect Part B during the General Enrollment Period to enroll in a Medicare Advantage plan with drug coverage (MA-PD).

Open Enrollment Period (OEP) 

The Open Enrollment Period allows Medicare beneficiaries to enroll in, disenroll from, or change a Medicare Advantage plan.  Like the General Enrollment Period, the Open Enrollment Period extends from January 1 through March 31 each year.  Unlike enrollment in Part B, the change in Medicare Advantage enrollment or disenrollment becomes effective the month after the change is made. 

Any beneficiary who wants to change must have both Medicare Part A and Medicare Part B and must live in the area served by the Medicare Advantage plan. 

Beneficiaries may not add or drop Part D drug coverage during the Open Enrollment Period.  Those who already have drug coverage can only change to another option with drug coverage. 

Special Enrollment Period (SEP) – for the working aged

Beneficiaries who delay enrolling in Part B because they are covered by employer-sponsored health insurance as an active worker or as a dependent of an active worker, are not limited to enrolling in Part B during the general enrollment period.

They have special enrollment, that runs for eight months from the time they (or their spouse) retire or they lose their health insurance. Part B coverage starts the month after the election is made, and no late premium penalty is assessed.

Special Enrollment Period (SEP) – for others

A number of special enrollments exist for Medicare Advantage and Prescription Drug Plan (PDP) enrollment and disenrollment.  For example, someone who moves out of a Medicare Advantage Plan or PDP service area has special enrollment to enroll in a plan that serves their new location. Beneficiaries, who move into, reside in, or move out of a nursing home may also have a special enrollment.

About two weeks after filing the appeal I received a call from the insurance company with an offer to attend the appeals hearing.  My response was a quick yes; I am planning to be on the conference call. One week before the scheduled call, I receive, yet another message, asking if we could change the date. We move the appeals conference call up a few days. The day of the new date, I receive another call. In this conversation, I am told, “there is no need for the hearing; the denial has been overturned and payment will be made in 30 days”. 

 30 days later we are still waiting for payment.

Naturally, I call the insurance company.  I am advised that there was an error and please excuse the delay. The insurance company is correcting this error and promise to move this, now approved medical bill, along for processing. This will take another 30-45 days.

  The House of Representatives approved a revised version of the healthcare bill last night.  The 219 Democrats and 1 Republican call it a bill defining social policy achievement.

I wonder how many of these Democrats will be making this same statement four years later.

Voting no for this bill are 39 Democrats and 176 Republicans.  Perhaps the House of Representatives is thinking the same way as Kevin Brady (R-TX) who was quoted in the New York Times saying “This government takeover has got a long way to go before it gets to the President’s desk, and I’ll continue to fight it tooth and nail at every turn. Health care is too important to get it wrong.”

 I also wonder if George Miller (D-CA), the chief architect of this bill, will call it revolutionary in 10 years and 1.1 trillion dollars later.

Republican consensus is that this bill is too costly and will end up hurting our fragile economy even further.

“This bill is a wrecking ball to the entire economy,” said Representative Jack Kingston (R-GA). “We need targeted specific reforms to help people who have fallen through the health care cracks.”

The House bill is 1,990 pages long and requires most Americans to obtain health insurance or face penalties. Most employers will have to provide insurance coverage or pay an 8 percent tax penalty. According to Virginia Foxx (R-NC), “More taxes, more spending and more government is not the plan for reform the people support.” Other Democrats argue that this bill will bring the health care cost under control.

It may be naive to ask, but why aren’t the 15 million government employees joining the public option as their source of insurance?  This would ensure firsthand experience for Congress, the actual creators of the plan.

According to Medicare (Center for Medicare and Medicaid Services- CMS)  approximately 7% of beneficiaries enrolled in Medicare Advantage (MA) plans will have to choose a new health plan or rejoin original Medicare before December 31. This change will take place, because many of the current private Medicare plans did not renewed its contract.
If members of this group do nothing they will be automatically re-enrolled to traditional Medicare, without supplemental and prescription coverage.

CMS is responsible with providing Medicare beneficiaries the information they need to make informed choices. This includes general information to remind beneficiaries that a Medicare Advantage plan may choose not to renew its contract with Medicare.
The obligation to provide direct and specific information about the nonrenewal to plan enrollees falls on the MA organization (specific insurance company) that sponsors a plan whose contract it does not intend to renew. The MA organization must provide plan enrollees with a notice 90 days before the end of the year. The notice must include a written description of alternatives available for obtaining Medicare services within the service area, including alternative MA plans, Medigap options, and original Medicare. The MA organization must also provide notice to the public within the same period, generally through publication in a newspaper in the community it will no longer serve.

Because notification regulations were developed before enactment of Medicare Part D (PDP) , they do not specifically require non-renewing plans to include information in their notice to enrollees about prescription drug coverage. As a result, beneficiaries may not receive sufficient explanation of the need to enroll in a PDP by December 31, 2009. Most beneficiaries who return to original Medicare and who do not choose a drug plan will find themselves without prescription drug coverage in the New Year.

Despite rules that are intended to protect enrollees in private Medicare plans that are not renewing their contracts, beneficiaries still bear the burden of ensuring that they have complete health care coverage. Those who do not choose another MA plan will have original Medicare, Parts A and B, to provide for most of their health care needs. However, they will not have prescription drug coverage unless they take affirmative action to choose a PDP. They also may want a Medigap policy to assist with Medicare’s cost sharing.

The Senate Finance Committee approved their version of the healthcare bill. This proposal eliminated the public option and left states to fend for the uninsured and formerly untaxed medical coverages and insurances are now ridden with taxes — insurance policies that cost over $8,000 annually will herein be taxed.  Individuals without insurance will be penalized.
The new proposal contains long needed reforms, such as elimination of any pre-existing conditions penalties as well as the removal of lifetime caps.  Other measures, such as elimination of co-pays and deductibles, could be beneficial but we all need to remember that added benefits carry added cost.  

Both houses are working to combine five healthcare proposals to come up with two competing bills. Somewhere along the line, Congress lost track of the need to devise a bill that is best suited for this nation as a whole. The goal now is to formulate a bill that will pass with enough votes.

Healthcare reform is too important just to pass any bill. The erroneous bill will do more harm than good.

The pre-existing condition is a health condition or illness that you have had before your first day of coverage on a new plan. The actual health coverage for those with pre-existing conditions depends on a number of factors such as the type of health insurance plan, the level of care that required for your pre-existing condition, and your health insurance history. A person with a pre-existing condition can cost an insurance company big bucks and naturally, it is in their best interest to exclude those who have them.

On the ligth side, here’s The Wizzard of ID cartoon that does describe the meaning of pre-existing condition on a morbid way: