Changes to Part D plans come in different forms: a higher monthly premium; drugs being dropped from coverage; brand drugs being moved to a higher tier with a much higher co-pay.

This weekend I was checking on Part D plans for the husband of one of my clients.  He takes Exforge, and I discovered that not all plans cover this drug.  I emailed my client, the wife, to inform her that the Part D plan she has does not cover Exforge. Rather than email me, she called me up to say that she takes Exforge and it is covered by her plan.  Hmmm…

Note:  Because I am an insurance broker, I am not allowed to name names, lest someone think I am promoting a plan or plans.

I used the Medicare.gov Plan Finder to look at 2012 coverage, so I went back and looked at information for 2011…  and I saw that Exforge is covered this year by my client’s plan.  Then I went to the website for her Part D plan and typed in Exforge to see if it is covered for 2012.  I found that it is not covered in 2012. Just to be sure, I called the 800 number on the website and talked to a company representative who told me that Exforge is covered this year but not next year.

My client was surprised to learn about this important change in her plan, one of the most popular Part D plans (in terms of enrollment). I don’t know if she was informed of this change.  It might have been included in the materials all Part D and Medicare Advantage plans are required to send to each enrollee in September. Most people do not read the Annual Notice of Change that informs them of changes for the coming year. So we stumbled onto very important information that will require my client to switch to another Part D plan so she can continue to take Exforge.

11/13/11 UPATE: I was looking for information on the AARP Medicare Rx Part d plan, I found the following information on one one of their web pages. It tells me that everyone does get information about changes to their plans – if they read it.

2012 Formulary Changes
If you’re a continuing member in the plan, you’ll receive an Annual Notice of Changes (ANOC). You may notice that a formulary medication you are currently taking is either not on the upcoming year’s formulary or its cost-sharing or coverage is limited in the upcoming year. If your drug has been removed from the formulary or has a new requirement and limit that you must follow, the plan will send you a separate communication to notify you.

CHANGES I’VE DISCOVERED

I’ve already written about the Part D plan that is going from $33 per month to $71.

One Medicare Advantage plan is moving Lipitor from tier 2 to tier 3 with a $95 co-pay.  It has always been a tier 2 drug with a $42 co-pay.  Lipitor is going  generic later this year, so that may be why the company is raising the co-pay for this drug.

The lesson here is that your Part D plan, whether it is a stand-alone plan or part of a Medicare Advantage plan, might be changing. And you need to be sure your brand drugs are still covered, or are not going to double in price. And I’m not sure anybody needs to pay $71 for a Part D plan that doesn’t even cover all drugs.

WHAT TO DO

For people who are comfortable with the internet, this information can be found on-line – though some company websites are easy to navigate while others are pretty challenging.  If you are not computer savvy, you can call the phone number for customer service/member services on the back of your Part D or Medicare Advantage id card.  Ask the customer service rep to tell you what your co-pay will be for your brand drugs in 2012.

Remember: If you snooze you lose. Don’t wait to discover these changes in January when it will be too late to change your Part D plan or your Medicare Advantage plan.  You can fill out the forms to change your plan up until December 7th.  Your new plan would take effect on January 1.

If you want to know more about Medicare, Medicare Part D, Medicare Advantage, who qualifies for Extra Help, and much more…. click the image below.

Healthcare reform now requires health insurance to cover preventive screenings at no cost to the patient. (I am talking about under-65 health insurance, not Medicare.) That means an annual visit to a primary care physician, nurse practitioner, or a physician’s assistant.

Note: The new rules apply to new health insurance plans or insurance policies that began on or after September 23, 2010.

People are encouraged to get these screenings even if they have a high-deductible health insurance plan. But it turns out some people have been surprised to find their free visit to the doctor resulted in a substantial bill. The surprise bill is due to the doctor going beyond the annual consultation and providing additional services, such as discussing symptoms that would require a diagnosis of a problem.  Apparently this is beyond the scope of a consultation for a physical, and results in the doctor generating another bill – something the insurance company is not required to pay if the patient has a plan with a deductible that has not been met.

In Connecticut, two patients filed complaints with the state’s Attorney General when they got surprise bills from what they thought were annual physical consults with their primary care doctors. They assumed they would have no co-pay for the visit to the doctor.

According to an article in The Day newspaper in New London, Connecticut:

[Doctors] are able to tack on these extra fees because there are no set guidelines by the American Medical Association or any other medical body that specifies exactly what an annual physical should include. This permits doctors and medical practices to unilaterally decide what is included and what they can bill for extra.

“We discovered,” said Attorney General spokeswoman Susan Kinsman, “that the threshold determination of when significant additional services are rendered is made largely on a case-by-case basis and … appears to permit services that may seem minor to a layperson, to be considered significant to a physician or billing agent.”

The two patients in Connecticut who complained were put on a “do not serve” list by the Hartford Medical Group, which is one of the largest medical practices in the state of Connecticut. They got some vindication from an investigation by the state’s Attorney General. The Hartford Medical Group agreed their doctors should advise patients when an examination goes beyond the scope of a preventative wellness exam that would generate another bill.

Medicare now covers more preventive services.

Seniors are being encouraged to take advantage of these “free” Medicare benefits. But they might be surprised to find they actually need to pay something because of the scope of the appointment with their doctor.

A client of mine said she was surprised to get a bill for a $40 co-pay when she went for her annual exam with her gynecologist.  She is enrolled in a Medicare Advantage plan. As we talked about the bill, she told me she has a particular female condition  – and I surmised that the doctor was doing more than an annual exam, which resulted in the co-pay to see a specialist. My client was not upset with the co-pay, but she was happy to understand why she had to pay it.  Of course, this information probably should have come from the doctor rather than an insurance broker.

The list of preventive services covered by a person’s health insurance can be found at http://www.healthcare.gov/news/factsheets/2010/07/preventive-services-list.html  This is not the Medicare list.  This is for people under 65.

For a list of Medicare-covered preventive services look here: http://www.medicare.gov/navigation/manage-your-health/preventive-services/preventive-service-overview.aspx

There’s a full-page ad in today’s Arizona Daily Star for a Medicare supplement company. The message is to pick a Medicare supplement based on the company with the lowest price.

What to ask about the pricing for Medigap plans:

Ask the question, “How much will this lowest-priced supplement go up in a year?” Then ask, “and what about three months after that, or at the two-year mark? How much will my premium go up within two years?”

Every insurance agent, or the helpful person at a company’s call center, should be able to give you an answer.

The problem with choosing a Medicare supplement based on the lowest price is that that price will certainly go up over time. And if the price goes up 30 to 40% in one year (or just over a year), you may not be able to go shopping for another Medicare supplement.

With Medicare supplements, when a person turns 65, or first gets Part B of Medicare, he has six months to buy a Medicare supplement without answering any medical questions. But after that, when the premium has skyrocketed, that person will have to answer medical questions if he applies with another company. And if that person has health problems (diabetes, cancer history, heart disease….) he can be turned down for coverage.  He will then be stuck with that Medicare supplement policy with a premium that will go up 20 to 40% each year.

So be sure to ask what the average price increase is after one year, or two years.  If the person you’re talking to won’t give an answer, you should walk away or hang up the phone.

To learn more about Medicare supplements, Medicare Advantage, Part D, and much more, you might want to take a course on  Medicare. Click on the image below.