As individuals retire or age into Medicare, their insurance situation can change dramatically. There are a multitude of options open to those with Medicare. The terms, prices and products offered are dramatically different each year.
The purpose of this column is to give those who are eligible for Medicare, or soon to be eligible for Medicare, some understanding of their insurance options and how it could impact their health and finances.
These questions and answers are meant as a guide to help you understand the complex questions you are now thinking about. Each individual's specific situation may create a different solution. You shouldn't necessarily do what your friends, family and neighbors do.
Question: I have a Medicare Part D prescription drug plan. I keep getting notices from them and don't know why. I get a print out from my pharmacy when I pick up my medications, why am I getting this as well?
Answer: Centers for Medicare and Medicaid Services sets a standards of practice as part of the policies that the Medicare Part D Insurance companies have to abide while providing prescription drug coverage to those enrolled in their plans. This monthly claim report is one of those standards of practice.
Each insurance carrier must send each individual enrolled in their plan a monthly listing of the medications filed under their claim number. This information can be very useful to you. It includes the medications you filled, how much you should have paid, and where you are in the different categories of coverage.
You want to look at these mailings. First look to see if the medications filled were medications you actually received. There may be billing errors. Someone could be filling medications under your claim number, and thereby getting you into that doughnut hole or coverage gap sooner than necessary.
You also want to look to see that the amount you were supposed to pay was the amount the pharmacy charged you. There are sometimes errors here. If you find that your pharmacy receipts do not match the amount the insurance company indicates, you need to take your print out to the pharmacy to see if they can resolve the problem. If not, call your insurance carrier to talk about this discrepancy. You may be able to file a claim to receive any overpayment back from the pharmacy or the insurance carrier.
This notice also tells you where you are in the coverage of your medications. Remember that the Medicare Part D plans have categories of coverage. The first type is the deductible - usually $275. The deductible, if you have one, is where you pay full price for your medication. Once you have met your deductible, you begin to save money on your medications, called your initial coverage limit. This savings lasts until your total cost of Medications reaches $2,510.
The total cost includes both what you and the insurance carrier have paid for your medications. If you are still getting medication at this point, you reach the coverage gap - doughnut hole. At this time, you again pay the full price for the medications you receive.
The coverage gap lasts for $3,216.25. Now I know this is a different dollar figure than you usually see. I am taking the amount from $2,511 to $4,050. I know the math doesn't seem to work, but the amount of $3,216.25 also includes your deductible previously paid and any co-pays paid during your initial coverage limit. All this applies to your total out of pocket of $4,050 per year. After you have paid $4,050 - if you get that far, and I hope you don't - your costs reduce significantly, because you have reached the catastrophic coverage limit. This period means your co-pays go down to 5 percent of the total drug cost.
All this was said to remind you to review those monthly notices from your prescription drug coverage carrier. These monthly notices provides valuable information to you. Also save these notices - that way if there is an error, you have proof to fight that error. If you switch companies you can check to be sure your coverage has transferred properly. The money you spend under one carrier at the pharmacy carries over to your new plan. You don't start all over with your coverage if you switch plans in the middle of the year.
Janell Sluga is a geriatric care manager certified and works for Senior Life Matters, a program of Lutheran Senior Housing. She has worked in Chautauqua County with Seniors for more than 16 years. She is HIICAP - Health Insurance Information, Counseling and Assistance Program - counselor trained by Office For the Aging.
She does not sell insurance, or represent any insurance company. She is an unbiased source of insurance and education to help seniors choose the best option for them.
You may submit questions to be answered in later columns to Janell Sluga, at Senior Life Matters 737 Falconer St. Jamestown, NY 14701 or by e-mail at janells@lutheran-jamestown.org. Please remember that not all questions can be answered in this format, but as many as can be, will be.