Open Enrollment for Obamacare and Medicare —By Jacques Chambers

Open Enrollment for Obamacare and Medicare
—By Jacques Chambers

Medicare Open Enrollment starts October 15, 2015 and ends December 7, 2015.
All changes made during this time are effective January 1, 2016.

Affordable Care Act Open Enrollment runs from November 1, 2015 through January 31, 2016.
The effective date will be based on when the changes are requested;

• If made on or before 12/15/2015 – Changes effective on January 1, 2016
• If made 12/16/2015 through 01/15/2016 – Changes effective on February 1, 2016
• If made 01/16/2016 through 01/31/2016 – Changes effective on March 1, 2016 

Employer-Provided Benefit Programs also frequently provide an Open Enrollment Period for employees, allowing them to make changes in their employee benefits choices. Although employers can select other times of the year, most employers who offer one have their Open Enrollment in November and/or December for a January 1, 2016 effective date.

Medicare

Medicare beneficiaries have the opportunity to switch their coverage from any to any of several choices:

Original Fee For Service Medicare – Parts A and B of original Medicare are the same for everyone; however, each beneficiary can elect the prescription drug plan in which to enroll. The best way to do this is to compare plans using your own current prescriptions, since your medications may have changed and plan formularies and prices also change.

There is a program on line at www.medicare.gov that allows you to enter your medications, which pharmacy your prefer, and where you live; it will then show you what each plan would cost you out of your pocket based on your medications.  Click on “Find Health and Drug Plans” and follow from there. I recommend the “General Search” rather than the personal one; it is much quicker and just as accurate. If you are on particularly expensive medications, once you find a drug plan, you should confirm the coverage and what you will pay directly with the insurance company as errors sometimes occur.

Even if your current Drug Plan has been serving you well, it is still advisable to run the program. The plans for 2016 are already up on the website.

For persons who are not comfortable with computers, Medicare’s toll-free number (800-MEDICARE) will do the same calculation.  However, I recommend you find a friend or relative who will do it for you on a computer because the results are too long and involved for a telephone operator to spend much time reviewing the options based on your specific needs.  

Medicare Supplement (also called Medigap) Plans – This open enrollment period does NOT apply to the Medigap Plans sold to people with Original Medicare to “fill the coverage gaps” left by Medicare Parts A & B.  To find out when you can purchase them, go to www.medicare.gov and search for “When Can I Buy a Medigap Policy”. It will list the Open Enrollment opportunities for them. They may also be purchased at other times, but the insurance company may require proof of good health.

Medicare Advantage Plans – These are plans offered by insurance companies and health service providers and are an alternative to Fee-for-Service Medicare.  Many of these plans are run by Health Maintenance Organizations (HMOs), but there are also Preferred Provider Organization Plans (PPOs), Exclusive Provider Organizations (EPOs), Special Needs Programs, and Private Fee-For-Service plans, although all types are not available in all areas. All Medicare Advantage Plans must offer all of regular Medicare’s benefits and may add more.  Some plans may also charge an additional premium, usually relatively small.  These plans frequently include the prescription drug coverage in their plan so you don’t have the additional task of finding a Part D drug plan.

During this Open Enrollment Period, persons may switch from one Medicare Advantage Plan to another or move back to or away from Fee-For Service Medicare.

NOTE: If you move from a Medicare Advantage Plan to Original Fee-for-Service Medicare, you have until February 14, 2016 to enroll in a Part D Drug Plan.


Affordable Care Act (Obamacare)
Persons enrolled in coverage, as well as those who have not yet joined, have the opportunity to enroll into or change health plans under the Affordable Care Act.

Many plans are making changes in coverage as well as cost, so I do recommend you go to your state’s health exchange, or to www.healthcare.gov for people in those states that do no operate their own exchange, and search to see if there is better coverage for you.

Since most of these plans use network providers, you should confirm directly with the insurance company that the doctors and hospitals you prefer are part of the network. Also, make sure your medications are on the plan’s formulary.

Employer Provided Benefit Plans 
Employers offering an Open Enrollment period for their employees will publish (or offer online) an Open Enrollment Guide that spells out each employee’s current benefits plus the available options, opportunities, and costs that may be chosen during this period. For persons dealing with a serious medical condition like HCV, it can be an opportunity to alter benefits and, in some cases, actually increase benefits since these programs usually offer more than just health insurance.

Life Insurance. Persons dealing with HBV/HCV are generally unable to purchase life insurance in the individual market. An employer may give all employees a base benefit from $10,000 to $50,000, and a few will allow employees to purchase additional coverage. If your employer offers supplemental life insurance above what he or she offers; see if there is an amount you can purchase that will not require evidence of good health. If it is available, it is an excellent way for an otherwise “uninsurable” person to obtain additional life insurance.

Long Term Disability.  Less common, but still occasionally available, is the opportunity to increase the benefit of your LTD plan.  Some employers will provide a basic benefit for LTD, such as 50% or 60% of your monthly earnings, and allow employees to purchase an additional 10% or 15% to raise the benefit they would receive in the event of disability.

Some employers may allow you to add this benefit if you did not elect it originally. Again, it is important to read your Open Enrollment material to see if your employer offers this and if proof of good health is required.

Revising LTD Premium Payment. One additional possibility to explore is the payment of LTD premiums. Some employers will allow you to have the premium they pay for your LTD coverage added to your W-2 making the premiums taxable rather than receiving it as a tax-free gift. If this is possible you may want to jump at the chance, the reason being tax-free disability benefits should you become disabled.

If you pay for the LTD coverage with money that is taxed as income, then the benefits you receive if you become disabled will be income tax free, substantially increasing the spendable dollars you would receive as a disability benefit. The rule is the IRS will tax either the premium paying for the coverage or the disability benefits being paid out, but not both.

Health Related Benefits.  Many employers, especially larger ones, offer a variety of health, dental, and vision plans from which employees can choose.  At Open Enrollment, you have the opportunity to change your coverage from one plan to another regardless of your medical condition, and sometimes have the opportunity to make choices within your plan, such as increase or decrease the size of the deductible.

For someone dealing with HCV, this can be an important choice, especially if this is the first Open Enrollment since diagnosis.  There is no one type of health plan that is best for everyone. There are two main kinds of plans that employers offer most often:

Preferred Provider Organization (PPO) – These plans provide some coverage for all physicians, but pay more if you choose a physician that has contracted with the insurance company, a Participating Provider.  This plan will give you the greatest flexibility in medical providers; however, it will often cost you more out of pocket for both your portion of the monthly premium as well as the plan co-pays and co-insurance.

Health Maintenance Organizations (HMO) – These plans usually offer the lowest out-of-pocket expenses, but limit your choice of physician. Coverage is only provided when using one of their contracting doctors and hospitals.  Also, a Primary Care Physician (also called a Gatekeeper) oversees all your medical care and must refer you to a specialist before the HMO will cover the specialist’s charge.

Exclusive Provider Organization (EPO) – These plans are exactly like an HMO except, there is no Gatekeeper physician. You decide if you need to see a specialist and make the appointment directly.

Which plan is better for you will depend on which doctors you wish to retain and what HMOs or PPO plans they are part of, as well as the cost to you.

Medicare spending for hepatitis C cures surges

Medicare’s prescription drug program spent nearly $4.6 billion in the first half of this year on expensive new cures for the liver disease hepatitis C — almost as much as it paid for all of 2014.

Rebates from pharmaceutical companies — the amounts of which are confidential — will reduce Medicare’s final tab for the drugs, by up to half. Even so, the program’s spending will likely continue to rise, in part because of strong demand.

Medicare’s stunning outlays, spelled out in data requested from the government by ProPublica, raise troubling questions about how the taxpayer-funded program can afford not only these pricey medications but a slew of others coming on the market

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Disability and Benefits:Medicare at Age 65, by Jacques Chambers, CLU

Originally Published July 15, 2015

This column has written about Medicare fairly regularly, however, eligibility for Medicare has usually been focused on those who get it after collecting Social Security Disability benefits for 24 months.

Perhaps it would be appropriate now, with improved treatments and a cure for HCV, to look at the process of enrolling in Medicare when turning age 65. Unlike those on SSD who are enrolled automatically in Parts A & B of Medicare, people turning age 65 must actively choose whether or not to enroll in Medicare in addition to deciding which parts are appropriate for them.

This is especially important because if you don’t enroll in Medicare at the appropriate times penalty surcharges can be added to the premiums and they will last as long as you are on Medicare.

For people who are already on Medicare due to disability, you are entitled to the same enrollment opportunities at age 65 as those just joining Medicare. It is your chance to make changes.

Here is a summary of the various parts and choices of Medicare:

• Part A Hospital – This covers hospital-related charges as well as Skilled Nursing Facilities and hospice care. Most people have paid sufficiently through MedFICA payroll taxes so there is no charge for Part A. For those that have not, there is a premium charge based on how many “work credits” you accumulated while working.
• Part B Medical – This covers other Medical charges, such as doctors, lab tests, X-rays and other tests, durable medical equipment, and some injection medications. The premium in 2015 is $104.90 per month, although high income persons pay a higher premium.
• Part C Medicare Advantage – These are Managed Care Plans from insurance companies, HMOs, PPOs, etc. Persons who are enrolled in Parts A and B of Medicare can “trade” that coverage for one of these plans. Most of them also cover prescription medications, and many do not charge a separate premium over the Part B premium; which must still be paid.
• Part D Prescription Drug Coverage – This coverage for prescription drugs is offered by private insurance companies, although all plans must meet the federal law’s requirements for such plans. Premiums vary by plan. To find the best Part D plan for you, go to www.medicare.gov; click on Find Health and Drug Plans. You can enter your medications to find the plan that covers them for the least out-of-pocket expense to you.
• Medicare Supplement (Medigap) Plans – These plans are offered by private insurance companies and are designed to accompany Parts A and B and cover portions of medical charges not covered by Parts A and B. There are ten different levels of coverage, and premiums vary by plan and insurance company. Since these plans are private insurance plans, if you do not enroll during the Initial Enrollment Period, you will be required to go through medical underwriting to purchase a plan later.

Initial Enrollment Period. If you are newly eligible for Medicare because of turning age 65, you can enroll in Medicare Parts A, B, and D or a Medicare Advantage Plan (Part C) during the initial 7 month enrollment period. The Initial Enrollment Period begins three months before the month you turn 65, includes the month you turn 65, and ends three months after the month you turn 65. The coverage will be effective on either the first of the month you turn 65 or the first of the month following your enrollment, whichever comes later.

NOTE: You can enroll in Medicare on line at www.ssa.gov, by phone at 800-772-1213, or at your local Social Security office. During this period you also may enroll in a Medigap policy regardless of your medical history or condition; you will need to do that directly with the insurance company or through an insurance agent. 

Late Enrollment. If you do not enroll in Medicare during this Initial Enrollment Period, and you do not qualify for a Special Enrollment Period, described below, then you must wait to enroll in Medicare during the annual General Enrollment Period.

Late Enrollment Penalty. If you do not enroll in Medicare during the Initial Enrollment Period and you do not later qualify for a Special Enrollment Period, the premiums you pay will have a penalty surcharge. The surcharge varies slightly by which part of Medicare is late in being enrolled; however, it is about 10 – 12% additional for each year you could have enrolled in Medicare but chose not to. This surcharge will be added to the regular premium during the entire time you remain on Medicare.

General Enrollment Period. General enrollment is from January 1 through March 31 of each year, with coverage effective the following July 1.

Choices When Enrolling in Medicare. Enrolling in Medicare requires making choices. Before enrolling in a plan you should do some research to make sure you are getting into a plan that meets your needs.

First you will need to enroll in both Part A (hospital) and Part B (Medical); see Special Enrollment Period below for exceptions.

Your primary choices for coverage are:

• Remain with Parts A & B, and add a stand-alone Prescription Drug Plan, Part D. You may also want to add a Medicare Supplement Plan (Medigap) to cover deductibles and co-insurance that Part A and B do not pay.
• Trade your Parts A & B coverage for a Medicare Advantage (Part C) PPO or HMO. You will still have to continue paying the Part B premium. Most Medicare Advantage Plans include Part D Prescription Drug coverage in their plan. For those that do not, you will need to purchase a stand-alone Drug plan to go with it. If you consider this option, make sure the medical providers you wish to continue seeing are contracting or preferred providers with the plan you choose.

As you might imagine, to find the right combination of coverage for you, you will need to do some research and perhaps speak with an insurance agent that specializes in health coverage for people age 65 or over.

Special Enrollment Periods
Not everyone who turns 65 needs or wants to switch their health insurance to Medicare. For those with a valid reason for not joining Medicare at age 65, provisions are made to allow enrollment at a later date without being subject to Late Enrollment Penalties.

Many people who already have health insurance when reaching age 65 want to continue their coverage. That is not always a good idea:

• If you have individual health insurance, and it is not from the Affordable Care Act, you may keep it, but chances are you will have better coverage for a lower premium if you enroll in Medicare A, B and D plus purchase one of the broad Medigap plans.
• If you have individual health insurance that is from the Affordable Care Act, the same would apply as the premium subsidies are no longer available after age 65.
• If you have insurance through an employer due to current employment by you or your spouse, you may wish to postpone signing up for Medicare. You can sign up for Medicare anytime while covered. Also, when your employer-based coverage stops, you have an 8-month Special Enrollment Period to sign up for Medicare.
• NOTE: COBRA Continuation Coverage is NOT considered to be from active employment so the 8-month enrollment period begins when your “active employment” coverage stops.
• To enroll in a Part D Prescription Drug Plan during this period you will need to provide a letter from your employer’s health insurance carrier, called a “Certificate of Creditable Coverage” that states the drug coverage they offered was as good or better than Medicare Part D coverage. Most group plans meet this requirement.
• If you are covered under TRICARE (coverage for active-duty military or retirees and their families), you will be required to enroll in Medicare Part B once you retire.

There are other times when you may take advantage of a Special Enrollment Period:

• You move to an area that is not in your Medicare Advantage Plan’s service area;
• You move to an area that is still in your Medicare Advantage Plan’s service area but which now has options available in your new location; and,
• You move back to the United States after living outside the country.

These are the major periods when you can enroll in the parts of Medicare, but not all of them. If you are approaching age 65, you should get more detailed information by downloading the Tip Sheet, “Understanding Medicare Enrollment Periods” at: www.medicaresupplementplans.com/
publications/ Understanding_Medicare_Enrollment _Periods.pdf

http://hcvadvocate.org/news/newsLetter/2015/advocate0715_mid.html#3

Rural docs want looser rules for Hepatitis C treatment

INDIANAPOLIS – The only doctor at the center of an HIV outbreak in rural Indiana cannot prescribe the latest treatments for patients also infected with the deadly Hepatitis C virus.

Dr. William Cooke, a family practitioner in Scott County, is treating dozens of people with HIV, the AIDS-causing virus that exploded in numbers among intravenous drug users earlier this year.

But state Medicaid rules forbid him from prescribing new treatments to those same patients with Hepatitis C, the blood-borne disease that causes inflammation in the liver and now claims more lives than HIV in the United States.

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The White House signals a fight on high drug prices

On Monday, the Obama administration proposed taking a major step towards bringing prices down for expensive specialty medications.

In its budget, the White House calls for Medicare's prescription drug program to negotiate on prices for "high-cost drugs" and biologics, a complex and expensive class of drugs that is just starting to get competition from generics in the United States. "The administration is is deeply concerned with the rapidly growing prices of specialty and brand name drugs," the budget reads.

The Department of Veterans Affairs and state Medicaid programs get mandated discounts on these drugs, but Medicare was forbidden by the 2003 law creating its prescription drug program to negotiate on price. For years, liberals have been pushing to give Medicare that authority, which would make the United States more like the rest of the world.

It's not clear how hard the administration will fight for this idea, but you can add this to the list of budget requests that probably aren't going anywhere. Drug companies and Republican lawmakers have regularly pushed back against the idea of price controls in Medicare Part D.

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