Insurance Agent Forum

[blueblitz]

On group medicare. I encounter many small companies where they have employees over 65 years old still on their employers group coverage. The reason being is they are taking a lot of medications and are concerned with the donut hole if they go on an individual medicare plan. Any advice?

[midwestbroker]

Here is how I would go about it...

What is their premium now vs. premium on individual coverage?

If they go into the coverage gap, is there enough savings in premium to offset the cost of the drugs?

Are there state assistance programs that can help them (Missouri has MO RX that pays 1/2 the cost of the drugs)?

As long as their drugs and providers are covered, it all boils down to cost...just have to punch the numbers.

[Frank Stastny]

There are a number of reasons for people not to stay on their group plan after turning 65.

The first thing you need to find out is if they have taken Medicare Part B. If they are over 65 and still working and on the employers health plan they should not have taken part B. For their sake hope they haven't.

If they have both Parts A and B and still covered by a group plan then their group plan is primary and Medicare is secondary. This is going to cause him/her problems when they have a claim. They need to be aware of this.

If the prospect is still working and covered by the employers group health plan after going on Medicare, and the employer has more than twenty employees then the group coverage provided by that employer is considered to be primary coverage and Medicare is secondary. When Medicare is secondary the claim must first filed with the primary carrier. The primary carrier will determine the amount to be paid on that claim. If the claim is not fully paid by the primary carrier, the claim can then be submitted to Medicare along with a copy of the Explanation of Benefits (EOB).

After Medicare reviews the claim and the EOB they will determine the amount that Medicare would have paid had Medicare been the primary carrier. If the primary carrier pays an amount equal to or greater than what Medicare would have paid, Medicare will not pay any remaining balance due that may still be owed by the policy holder even though the primary carrier did not pay 100% of the claim.

Usually the group plan has paid more than what Medicare would have approved so nothing is paid by Medicare. This is going to leave the individual owing the balance. With Medicare and a Medicare Supplement policy their virtually is nothing owed by the individual. (They may owe the Medicare Part B deductible, but normally that would be all.)

In all likely hood the benefits are going to be a lot less with the group plan than they will be with Medicare and a Medicare Supplement policy. The group plan will most likely cost more also.

Regarding prescription medicine. If someone is taking a generic med then they should get it at one of the chain pharmacies that offer a thirty day supply for only $4.00. When they make that purchase they should not let the pharmacy charge it against their Part D plan. They should simply pay the $4.00. If the pharmacy uses their drug plan then the full cost of the medication is applied to the total before they enter the "doughnut hole". The retail cost may be $40 even though they only paid $4.00. This will go a long way in keeping them out of the "doughnut hole".

Just imaging if they are taking five meds at even $20 each, that alone is going to generate $100 per month, not the $20 per month that they pay. (5 meds x $4 each = $20)

A lot of people do not realize this and some pharmacies are telling people it is illegal not to use their Part D card. The reason is that the pharmacy makes more money if they can charge the retail amount to their Part D coverage.

Other talking points are: The group plan can be canceled; the group plan can change, most often reduce, benefits; the group plan most likely will have a network of doctors and hospitals, not so with Medicare and a Medicare Supplement policy.

If you would like to talk about it further give me a call.

[emptyeternity]

Frank what do you do when the senior has an MA plan, and you want to switch them to a med supp. How do you handle the medication? Do you offer PDP's?

[ronmelton3]

Some group plans coordinate with Medicare/Medicare Advantage/ PDP.
Many group plans at 65 require a person to pick up a Part D plan and then the group plan supplements it.
Some group plans do not coordinate and the client will lose his coverage at work for all eternity.
You need to contact the person who handles their group benefits and have them tell you:
1. Do you have to have Part B?
2. Do you have to have a Part D Drug plan?
3. Does your plan coordinate with a Medicare Advantage Only (no drugs) plan?
4. Who is primary?
I saw a plan yesterday, where medicare was primary, group health was secondary and the most that would be paid out on a claim was 80% with $2000 OOP. Since the Group plan would only coordinate to what Medicare would pay anyway, he wasn't require to take Part B. A saving of $96.40 in his case. His Group Health drug plan wouldn't coordinate with Part D, so we left that alone. He was only paying $89 a month for his Group Health w/RX. I wrote him an Indemnity Plan to pay his other 20% with Continental.

[coachd]

Frank,
Thank you for your education. I am still trying to get into more homes. The things you share are great for helping me sell.

[Frank Stastny]

Originally Posted by emptyeternity

Frank what do you do when the senior has an MA plan, and you want to switch them to a med supp. How do you handle the medication? Do you offer PDP's?

The only thing they can do it wait until November 15 and sign up for another Part D plan. A lot of seniors I encounter take mostly generic meds. For those it really isn't a big deal to go without Part D coverage for a few months. They shouldn't be using Part D for generics anyway.

I let all of my clients know that I had Part D plans available the first year they came out. I have since stopped offering to sell Part D plans. I recommend that they take a list of their meds to their pharmacy and have the druggist look up their meds and recommend a plan to them.

There is no way that I can certify with all the companies offering Part D, nor would I want to. If I recommend a plan and six months later their most expensive drug it taken off of the formulary then my credibility is at stake. With the changes that are constantly taking place with Part D and the stringent parameters in trying to explain it to people I feel that their pharmasist is the best person to help them

[emptyeternity]

Thank you

[rbrewer]

If CMS wants to be so involved part D is the one area they should regulate. They should all cover the same thing. No wonder seniors heads are spinning. Their's about a million drugs who could keep up?
Oh and by the way: Frank you are a good man!

[GreenSky]

Originally Posted by rbrewer

Oh and by the way: Frank you are a good man!

Doesn't he have a big enough head already?

Rick

[rbrewer]

I don't know does he. Ask his wife, after nine years she will rat him out lol!

[InsureGuy5]

You would also want to consider their deductible should they have a major claim. That can make a big difference.

[rbrewer]

Originally Posted by emptyeternity

Frank what do you do when the senior has an MA plan, and you want to switch them to a med supp. How do you handle the medication? Do you offer PDP's?

You can switch to a med supp and keep the pdp they are on unless it is an mapd.

[InsureGuy5]

Originally Posted by rbrewer

If CMS wants to be so involved part D is the one area they should regulate. They should all cover the same thing. No wonder seniors heads are spinning. Their's about a million drugs who could keep up?
Oh and by the way: Frank you are a good man!

I agree. If we are going to have standardized plans for Medicare supplements, then the same should be true for prescription Part D plans. Keeping up with the formularies makes everyone's head spin. No to mention that most of the providers are uncertain as to what they cover too.