The 100 Redshirts – advisers that Independent Health has hired for the Medicare Advantage Plan sign-up season – will have a lot of explaining to do during the next 10 weeks. Higher-than-expected plan use this year and the skyrocketing cost of prescription drugs prompted the regional insurer to scrap its two most popular plans: one with no monthly premium, and another that costs $50 a month.
Three Independent Health plans for 2017 will include monthly premiums that range from $65 to $128, with varying copayments per plan. The remaining $0 plan won’t include prescription coverage.
The Amherst-based insurer – which handles slightly more than half the region’s Medicare Advantage enrollees – expects the scenario will likely be similar with its competitors as those 65 and older start shopping for Medicare supplemental coverage on Saturday. Seniors may still be able to find zero-premium plans but they may exclude some of the doctors they now see, some of the drugs they take and some of the hospitals they prefer to use.
RELATED STORY: Maximize your health with this to-do checklist
“It’s more than just EpiPens,” Independent Health spokesman Frank Sava said about rising prescription costs. Diabetes drugs jumped 18 percent this year and generic prices also climbed.
“We’ve seen increases in inpatient stays, skilled nursing care, oncology services,” added Linda Carr, vice president of government sales. “Our pharmacy costs have increased. We’ve seen a lot of joint replacements, a lot of low back issues, a lot of acute services ... and our government funding has gone down. People are living longer, too. We have folks who have been with us a very long time.”
Carr, 55, of Hamburg, holds a bachelor’s degree in organizational business management from Houghton College. She has worked with the Amherst-based insurer for 28 years – and understands deeply the unexpected turns, and costs, that health care can take. Her husband, Jim, owner of a small moving company, died in February 2015 after a 13-month battle with esophageal cancer. Their children, Brittne and Max, as well as Carr’s co-workers, have been a vital source of support through diagnosis, treatment and the aftermath.
Seniors can shop for Medicare Advantage Plans starting Saturday and sign up from Oct. 15 to Dec. 7. The main Independent Health Medicare information centers – Valu Plaza, 620 Dick Road, Cheektowaga, and Tops Plaza, 3225 Southwestern Blvd., Orchard Park – will be open 9 a.m. to 3 p.m. Saturday. For more information on other offices and hours, visit independenthealth.com or call 635-4900.
Q. You oversee Medicare, Medicaid, Child Health Plus and the individual marketplace (Obamacare). Which is the most complicated?
Medicare, hands down. It’s because there’s so many regulations. CMS – the Centers for Medicare and Medicaid Services – has very, very strict guidelines on what you can and can’t do. People are very confused about Medicare. It’s a lot to absorb. But it helps if you break it down, are transparent with people, and explain to them the importance of knowing if your doctor is in their network, knowing if your drug is in the formulary, that if you have a question, you can call or walk into a place like one of our centers, and somebody local is going to sit down and talk with you.
Q. What’s the typical range of time you spend with someone
About 45 minutes.
Q. What is the difference between the two Encompass 65 HMO plans and the PPO you will offer for 2017?
The Core HMO is the new one (at $65 a month). The Basic HMO is the other one (at $118 a month). The higher the premium you pay, the lower the copayment. They both have comprehensive benefits, the same benefits. Your out-of-pocket and your cost share is different. The difference with the PPO plan ($128 monthly) is the ability to go out of network. An example, for $65 in your premium, you’re going to pay $15 to go to to your primary doctor and $50 to your specialist. If you pay more in a premium, you’re not going to pay anything for your primary doctor and $25 for your specialist.
Some people want the ability to go to any doctor anywhere. As long as the doctor takes Medicare, that’s a PPO plan. You have to pay a deductible – ours is $500 – and you have to pay co-insurance instead of a flat co-pay. An example is if I have a daughter in California and I’m visiting, and she has a great allergist, and I want to go to that allergist because I have the same issues, if I was on a PPO plan and he took Medicare, I could see him and the plan would pay for that.
Q. A premier wellness package is in all of the plans. What does that include?
Vision: You get an eye exam and you get glasses. Dental: You get two cleanings, an exam and X-rays every year. You get a gym membership. And you get something people really have been asking for: hearing aids; coverage for hearing aids with a co-payment. And you get an extended, enhanced office visit. There’s no co-payment for that. When you go for your physical every year, so many members tell us, “I’m in and out really quick. I don’t feel like I get to spend enough time with the doctor.” These benefits are all built around wellness, prevention and the relationship between the physician and the patient. They’re going to spend more time for you and they’re going to develop a plan for you based on your health care needs. These are the benefits people ask us for. It has a value of $4,797.
Q. What are the most important questions to ask as you’re looking for a plan?
The first thing is, “Is my doctor in your network?” From there, ask about hospitals and pharmacies. Those are the three drivers in terms of access. The second would be, “Is my medication covered on your formulary, and at what cost?” We ask people to bring a list of their medications when they come in and we run an analysis and give them a computer printout that tells them what it would cost, what’s their copayment month by month. Make sure the hospital you like is in the network if that’s important to you. Everybody asks us about Roswell. Unfortunately, plans don’t tell you that Roswell may not be part of their network or a primary provider group.
Then, really sit down and look at, “What would my out-of-pocket costs be for the services I anticipate getting?” If someone is really interested in a zero-premium plan, we will say, “Go to medicare.gov and put in your ZIP code and your county, and you will find the plans that are available in your area.”
Q. Is this what those of every age in the insurance marketplace and those in employer-paid plans also can expect? Are the same forces driving costs of those plans?
Yes. People who usually choose a zero premium plan really don’t have any services. They say, “I don’t care, I’ll gamble. I’ve never been admitted to the hospital, I don’t take any drugs. But they can get a surprise, whereas seniors say, “Nope. I know that this is what I pay, I can afford these co-payments, I’m good.”
Q. What do you recommend to a child or loved one to a senior who is slipping a little bit or maybe is in the hospital or is having a health situation during this window of time? Should they come in?
We encourage, always, for adult children or family members to come in an sit with mom or dad. We see that a lot. It’s mostly daughters, not so much sons.
Twitter: @BNrefresh, @ScottBScanlon