I am assuming I’m going to get stuck on Medicare, so that means Part D to start.
As one of the drugs is $135,000/year (retail) (no, not on it yet - it’s coming), I am running into the term:
Medication Therapy Management (MTM)
Medicare’s definition seems harmless, until you’re old enough to read between the lines.
When I see things like:
“your insurance company will discuss your medications with you and then give you a list to discuss with your doctor”,
it sounds a lot like:
“We’ll let you know what we’ll pay for - your doc can either switch you or you can pay for it yourself”.
Is that a reasonable interpretation of what these plans are about, or am I being overly suspicious?
And, just to establish how naive I am, is it true that private insurance ceases at 65, and it’s either Medicare or nothing?
MTM, oh, MTM… The wonders I’ve heard, which who knows if they will ever come to pass…
Ok, basically, Medication Therapy Management (MTM) is where a pharmacist goes over all the medications you are on, and does a complete review of them. The idea is that we make sure that everything you are taking is for a legitimate reason, and more importantly, you are not on anything that you shouldn’t be. We also check if there is something you should be on that you are not. Basically, we do a complete medication review, and make sure there are no medications that are duplicated from different doctors, and that there are no obvious omissions (like, oh hey, you have diabetes, we should make sure you are on an ACE-I to protect your kidneys!).
MTM isn’t something you should be scared of, it is actually a good thing. A proper MTM review is beneficial to the insurance company, and also the patient. There are proven beneficial outcomes to a proper MTM review… The problem has been convincing insurance companies to pay for it.
No, not totally true. I have seen plenty of patients over 65 that are still on private insurance… Though, in almost all cases, they are even still working, or their spouse is still working, and they are covered under their employers plan. You can still get insurance besides medicare when over 65, however, unless you are in a group plan, in most cases it isn’t worth it monetarily.
I just tried to get a quote on individual policies and gave a birth date over 65. Medicare seems to be it.
I declined part B (I’m on SS Disability) because I saw how eagerly the medical profession greeted Medicare patients.
Oh well.
All of my drugs are prescribed by the same doctor (PCP). I also see nephrologists from the same UC Davis system, but they have yet to write anything. (Stage III renal failure).
How do you feel about both 15 and 30mg doses of the same drug? Insist that the dosage be altered to a single size?
I’ve learned that one of the drugs I use as a sleeper (a benzo) is not classified as a hypnotic - are you going to catch that? If so, what will your “recommendations” be? Can I politely tell you to stuff it and still get my 'scripts covered?
Who pays you? Are all such programs paid for in the same manner? Do some insurers do this in-house?
When you see something like Procrit, how many flags does it trip?
Note that pharmaceuticals administered at the doctor’s office (as opposed to self-administered at home) are covered by Part B, not Part D. Not sure if that applies to you, but it’s something to keep in mind if it does.
And bear in mind that prescriptions, as well as office visits, etc. have deductibles . . . which have gone up this year. And the sky’s the limit when you reach the so-called “donut hole.”
The insurance company I work for does do this kind of med review in-house, IF you have their pharmacy coverage and it’s not carved out to another Pharmacy Benefits Manager (PBM). They see it as a preventative and cost-savings measure. They will also, if you request it, have a pharmacist call you to do the review in person, answer questions for you, discuss potential cost-savings, and they can even do things like send pill boxes (free, as an aid to compliance) and coupons. It’s a great program, and the customers I’ve talked to who’ve taken advantage of it loved the one-on-one review and the information and help they got. As a nurse, I refer people to this program frequently - there are a lot who aren’t aware it’s part of their benefits.
From my quick scan, the “donut hole” is a lapse in script coverage from ~2800 to ~4500, at which point, it comes under “catastrophic” coverage and resumes.
The guy who called when I went to to a federal site to inquire about Medicare (it was either SS or Medicare) (we have farmed that out to private enterprise) assured me that supplemental coverage was available to cover deductibles (and maybe co-pays), but there was no avoiding that $2K out-of-pocket “donut hole”.
Anyway, assuming ACA stands*, the donut hole is scheduled to shrink over the next 6 years, and be gone in 2020.
ACA’s “have the Feds pay for everybody’s insurance from private insurers!” was the GOP’s alternative to the Dem “Fed pays directly”.
Now, not only have they repudiated that, they are now trying to offer to start the foot-dragging all over again.
Vote!
Recall!
Vote Again!
There’s no rule against buying a private regular insurance policy once you’re on Medicare, but it’s normally such a stupid financial move for most people that Health Insurance automated enrollment systems might not work so you may need to telephone them or speak to an agent. The only possible reason would be you need a lot of they type of services that private insurance covers but Medicare does not, which is really rare.
Of course, supplement policies are common to the degree most people have either them or a replacement plan.
So SSD provides insurance? If so, still be careful you won’t be charged penalty rates forever for declining Medicare Part B?
Yes - after 24 months on SS Disability, Part A is automatic and free; Part B is offered, but, if I declined it, it was not free.
I was quoted 104.90 for Part B by the fellow who called in response to my inquiry. Yes, he knew that I had A due to disability, and deduced that I had declined.
That seems to be normal, so maybe that was a no-penalty window at that point?
I turn 65 next July, so maybe there will be another penalty-free opportunity?
I am really hoping (quite possibly, against hope) that I will get ACA coverage - I can put up with co-pays a lot easier than I can deal with $1600/yr “donut” + combined premiums 2x ACA Silver, and a toss-up for Gold, wherein deductibles disappear. The only scary part is the 20% co-pay for surgery, which I’m getting closer to needing.
Medicare claims to cover all “end stage renal failures” enrolled or not (some Senator’s relative needed a transplant, is my guess as to why that one specific rule exists), so I’m not worried about dialysis. Doubt that I’d be a candidate for transplant (age, quality of life (it sucks to be me*)).
Maybe kick it up to Platinum (10% co-pay) long enough to cover the biggies?
as an American with enough income to ensure comfortable housing, a full belly, and still healthy enough to get about unassisted. As things are going, that is way ahead of many, for which I am grateful.
I was told to buy Part B + Blue Shield of CA’s “Plan F” to cover the deductibles for Plan B.
Also buy Plan D through a 3rs party program,
voila! no deductible, no co-pay
(except that damned “donut hole” between $2800 and $4500 of drug costs).
By counting on Plan F costing $104/mo the numbers work (except for the donut hole, which averages to $142/mo for 2014.
So the ACA Gold would be great, but Much better IF it would cover the friggin’ University of California system, through which I get healthcare. It doesn’t.
In fact, it doesn’t seen to cover any major hospital in Sacramento.
So:
Does anyone know if “help with premium” on plans purchased through ACA includes ANY policy? My insurer wants to switch me to a program which would cover U of C, but at a policy way above what I can affords unless I can apply the ACA discount to it. Can I buy anything except the Metal Plans through Covered California (CA’s ACA Exchange) program? I still can’t reach anyone who will even tell me if I’m enrolled.
I I could by Blue Shield’s “Basic PPO of HSA” (why do I suspect I’m not going to like whatever an HSA tuns out to be?) and get the ACA discount on the premiums, that would ne nice.
Next Q:
I was told the premium for Blue Shield’s Plan F of $104 applied to only those 65 and over? Is this true, and, if so, is there anyone whhho will write a Medicare Supplement to anyone with Medicare, regardless of age?
On results page click link that says “Medigap Policies Available to People under Age 65”
You can check which companies sell each policy from there.
ETA: Some states have regulations that insurance companies must offer Medicare Supplement polices to those on disability and Medicare if that insurer wants to offer plans to those over 65. Sort of an all-or-nothing approach.
There’s an intermediate step in there - after the screen by state, the “View all Medigap Policies”
Has a block of links in the upper-right corner “Addiitonal Tools and Information”. in there is
“When Can I Buy a Medigap Policy?”. That brings up the page which lists States in which it is available.
It does NOT provide links to those policies, or note the premium level compared to the Age 65 premium.
Yes, since BS of CA will sell me the policy, the list includes California. It doesn’t note that the premium is $650/mo if under 65.
ACA tax credits cannot be applied to anything except the Metal (plus the basic please sign up now, yuppies: dirt cheap catastrophic “Get Covered” policies).
And no, BS of CA will not contract with the University of CA for their ACA policies.
Never listen to the first 2 you speak to; talk to at least 3 people to get the real story
To add onto this, pharmacists can also look at the cost of your medications. I’ve seen people who stopped taking their medication altogether because they were prescribed brand name, looked at their co-pays and said, “NOPE!” and were unaware that there were generic alternatives that could be discussed with their doctors.
Other things that can be done during MTMs include: trying to consolidate the total number of pills if that’s a barrier to adherence, teaching correct administration and usage of items such as inhalers/injectables/blood glucose monitors, addressing non-pharmacological treatments and OTC recommendations, making sure you know what each of your medications are for and how to take them correctly, recommendations for certain vaccinations, etc.
These recommendations are generally for the patient’s benefit and they and/or their doctors are more than welcome to tell the pharmacist to stuff it (nicely I hope! :)) if they don’t feel it’s necessary.
I have script for both temazepam and clonezepam - I had to explain that to the same damn pharmacist 8 TIMES (same clinic, same doctor - NOT shopping around) Yes, I know they are both sleepers; no, I do not mix them, yada yada.
The eighth time, I was a bit shy of “nice” about it. It did, however, shut her up about it.
Regarding your initial drug cost problem – and maybe this is too late or irrelevant now – check with the manufacturer of said drug. These manufacturers often offer programs to deal with paying lower amounts. For example, MS Lifelines Reimbursement Specialists for the Rebif my wife takes. Retail on this drug is around $3K per month; this can/will eat up all your deductible in a single month. After talking with the people above, we pay a $50 copay and they pay the remainder.