Sunday, October 21, 2012

Medicare and Insurance {blech}

Insurance is a wonderful thing. Negotiating your way through the various offerings, what they cost, and what they cover can be a true nightmare.

Take Medicare, for example. I don’t know why it has to be so complicated. I’ve talked to countless companies (Blue Cross, AAA, and Humana just to name a few); I’ve been to a few Web sites (including the official Medicare site) and could only get one to actually send a representative out to talk to us. Everyone else wanted me to just go out to their Web site and figure out the best coverage that I could get for Ron. Right now, he’s on my group plan at work but because he is turning 65 in January, he’s eligible to take out the supplemental plans with no medical questions being asked. For him, that’s a big deal. If I keep him on my group plan, he might not qualify later. But, my issue isn’t really the monthly premium (although paying over $300 per month to insure just him is not in my financial comfort zone, especially with “donut-hole” amounts for prescriptions on top of that, plus co-pays and deductibles) – it’s the prescription cost. Medicare supplemental plans have what is called a “donut-hole” in them. Drug coverage is up to a certain dollar amount and then you pay fully out-of-pocket until you reach another certain dollar amount. Then you go happily along until you hit another level and then you fall into that hole once again – only it’s larger this time. Once you crawl out of that hole, you can “hope” that the rest of the year your hole is no longer a crater-sized hole.

Right now, on my group plan, we pay $250 per month for the two of us (I know, that’s a great premium and I’m not complaining). The coverage is adequate for most people. I have a $1750 per person deductible and $7000 maximum out-of-pocket per family. Since April, I’ve met the deductible for both of us (that’s $3500) and I’m well on the way to meeting the $7,000 maximum for the year. After you meet your deductible, insurance pays 80% of reasonable and customary, leaving the other 20% for us. That has added up to another chunk of change (going toward the $7,000 amount). Prescriptions are $17 for generics (90 day supply in most instances) and between the two of us, we have 24 generic prescriptions. Doing the math - $17 * 24 * 4 – it amounts to over $1600. Insulin (this is the kicker) is $180 for 90-day supply – but he takes two different kinds, so that is $360 for 90-day supply. That math is over $1400. Added to the generic costs, our prescription out-of-pocket for the year is easily over $3,000. Just the premium ($3,000), plus the deductible ($3,500), plus the prescription costs ($3,000) put quite the bite in our finances (just in case you thought I was just out here blowing my money on trips and things… hahaha). Add in the co-pays and you have the potential to be spending a lot of money medically (just this week I found out the co-pay on Ron’s new socket liners is over $350 so I should be seeing a bill for that any time; just got another co-pay bill for $1298 and they’d like their money in full but will let me make 4 equal payments {choke, choke}).

Medicare will take $99 out of his Social Security check beginning in January (he will get a 1.7% raise on his check but that is nowhere close to $99). I could decline Part B but I’m not sure that it is a good idea to do that. Supplemental policies that I’ve looked at are up to $160 per month. Part D (the drug plan) plans are anywhere from $20 and up (one I looked at last night was $44). So, now I’m up to a little over $300 just for Ron’s insurance. One particular plan has no co-pay and no deductible. That’s good… a savings of $1750 right off the bat. Prescription co-pays are lower (mostly) but right off the bat, in January (because of the cost of insulin) we would fall into one donut-hole – our out-of-pocket for the month would be over $1400. Yikes! I don’t really “have” $1400 in January for prescriptions. February and March, we’re OK but in April it’s a CRATER – forget the donut-hole. Out-of-pocket estimates are in excess of $2300 for his meds for the month of April. Seriously? $2300??? Well, if I don’t have $1400 in January, you can bet your bippy that I don’t have $2300 in April either. (Plus, I’m sure there is something about federal income taxes that will hit me then…) In a nutshell, the annual costs for the insurance plus his prescription out-of-pocket is roughly $7600 (the best combination of medical and prescription coverage) but not sure that includes what the government will charge for Part B (which is another $1188). If we changed how his insulin is given (vials instead of pens – and I’d just have to draw up the syringes and leave them in the fridge for him), it might save us a little bit of money. The above out-of-pocket assumes that I would be refilling ALL of his prescriptions in January, April, July, and October. They don’t really fall that way so the dollars would fall a bit differently but still be substantial in the months we had prescriptions filled.

So, do I save any money by putting him on Medicare? If I took him off my group plan at work, I’d go back to my policy that I get as a benefit from him retiring from Boeing. The premium is… $10 (yes, that is a “ten”) per month. No deductible. $10 office call co-pay. Generics are $7 per month. That’s a big savings for my coverage but taking into consideration that his premiums and such would go up, not an overall savings. I think in the grand scheme of things, it would be a savings but maybe the overall amounts wouldn’t fall in such a way that it would benefit us.

I don’t know why the whole thing is so darn complicated. Why do we have to have a donut hole (or crater)? Why can’t it just be we pay X amount for prescriptions each month, every month, and not fall into those high dollar situations? It’s enough to make you want to stop taking medications. I can see why seniors sometimes have to choose to eat or to take their meds as prescribed. I can definitely see us cutting back just to stretch things a bit more. Getting (and staying) healthier is a smart move, but it’s already too late for Ron. The best he can do is maintain (and his A1C, which measures your glucose levels over a three month average, is down to 5.9%, which is outstanding; anything before 7 is diabetic in excellent control). His creatinine and potassium levels are excellent so what we’re doing is working. We just have to keep that up.


Green Girl in Wisconsin said...

What a HEADACHE. If we just had a single-payer system, we could all be more productive doing things that matter and be healthier. Who benefits from such a mess of paperwork and rules?

Kathy's Klothesline said...

Have you checked the generic list that Walmart has? $10 for a 90 day supply. If I read this right, you are currnetly paying $17 with your insurance plan. That would save $7. It adds up. Then I got that huge savings with my AAA card. Keep in mind that I have NO insurance.
You just fill them without insurance and then check your policy to see if you can file them for a % reimbursment. Don't forget to get a print out from each pharmacy at the end of the year for taxes. There is also DME (durable medical equipment) that is usually bought out of pocket. Things like syringes, bandages, etc. Include that with your RX for a deduction. Some insurances will also reimburse for DME.
It is a nightmare trying to figure out the supplement coverage for Medicare. I dealt with it when I worked in the pharmacy. I think of it as a conspiracy to make old people go nuts!!!!

Pat said...

Ugh. I'm sorry I can't help you. You mention the word "insurance" and my eyes glaze over and I don't hear any words after that.

Jim is on medicare because he over 65; we didn't opt for any additional coverage. We are VERY lucky that Jim's government pension INCLUDES medical insurance so BOTH of us are covered under that.

When the new Medicare and Plan D was coming out, I thought that Walgreens offered help in explaining the benefits. Maybe you could ask them.

Also - my daughter has been searching for a health insurance plan and went to her local State Farm Agent. He acted like a broker and researched ALL the plans available for her - she was under NO OBLIGATION to choose ANY - his included.

Hope some of these hints help you.