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Bulletin Board – October 11th, 2019

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October 11, 2019

RUPA Members: Immediate Past President Bob Engelman took notes at the Aetna insurance presentation made at the RUPA Reunion in Dayton, Ohio last week. Lots of questions and answers remain!


This is NOT an endorsement or recommendation! RUPA does not have an insurance guru so your own research is required.


This eblast is very long, be patient. DO NOT CONTACT ME FOR FURTHER INFORMATION, I don’t have the answers and don’t use the company’s insurance plan.


To start with, no one at RUPA has the expertise to assess a medical plan. That’s something so important that each member should do his or her own research. I’ll include below the notes I took at the presentation we got at Dayton, but I suggest everyone calls the dedicated number we got, which is probably also included in the two information packages that arrived at my home, 866-246-8088, where they supposedly have a 96% approval rating by other groups covered by similar plans. I would think they can answer all of your questions. Following many of my notes, in brackets, are comments from a member’s wife who has been in the benefits business for about fifty years and has done a lot of research on the new United plan.


Here goes on my notes—

  1. This is an Employer-Sponsored Medicare Advantage ESA (Extended Service Area I think) PPO plan. It’s customized for United.
  1. There is NO network. Providers are not IN or OUT of network, so the co-pay is always the same.


[I have had three discussions with Aetna on this. There is a network comprised of hospitals and other providers who are contracted with Aetna Medicare Advantage. If you see any provider who does not accept the plan but do accept Medicare, your benefits are paid as if they are In-Network provided they agree to bill Aetna. If they do not agree to bill Aetna (two of my doctors will not) you will be reimbursed based on the Medicare Allowable Charge and will need to pay any difference. I can tell you there can be a huge difference in Medicare Allowable Charges are retail charges. You only need to look at any of your old Medicare EOB’s the see the difference.


If you read the section under the title MEDICAL DISCLAIMERS on the 6th page of the Plan Summary of Benefits you will read more detail about Out-of-Network/non-contracted providers. This plan does have a network of Aetna contracted providers. You could pay more out-of-pocket if you see Medicare contracted providers but they don’t agree to accept this plan. They may require you to pay retail.]


  1. It’s considered Medicare Part C – You get 1 EOB, which will show what both Medicare and Aetna paid. You will get a monthly EOB statement. You will present your new Aetna card to each provider. You won’t need to show your Medicare card, although I would bring it just in case the provider insists, but all claims must be made to Aetna.


[When I called Aetna to inquire about providers that accept Medicare but not Aetna Medicare Advantage I was told we would have to pay the provider and then submit an itemized bill ourselves to Aetna who would then reimburse the Medicare Allowable Fee. The key will be to confirm with billing at your providers office if they will agree to bill Aetna and accept the Medicare Allowable Fee. Otherwise, it would appear the provider can charge whatever they want and you have to pay the balance. The balance would NOT apply to the Out-of-Pocket Expense limit of $1,200. This is a question I will be posing again in the meeting at Dulles on October 18th.]


  1. Deductibles – $150. There is no Medicare deductible. Only this $150
  1. $1200 Out Of Pocket (OOP), then everything is 100% covered.


[Everything that is deemed a covered service under the plan. I understand that anything that is over the Medicare Allowable Charge is excluded from the OOP. The deductible of $150 also applies to the OOP. Also note, none of your pharmacy co-pays, deductible or co-insurance apply to the OOP Maximum of $1,200. The Silver Script plan has a deductible of $100 for RETAIL prescriptions and has a $300 OOP Maximum for the co-insurance of 20%. If you are taking a drug long term you use the preferred pharmacies, you won’t see any difference in most cases as the co-pays are still $16 for generics and $48 for a 90 day supply. If your drug spend reaches $6,350 the Catastrophic Coverage State kicks in with details on page 5 of the Summary of Benefits for the combined Aetna Medicare Advantage ESA PPO medical and SilverScript plan.]


  1. 100% covered for Preventive Care
  2. 100% covered for Diagnostic Care (outpatient)


[The plan will cover Outpatient Diagnostic Laboratory at 100%, Outpatient Diagnostic X-ray, Outpatient Diagnostic Testing and Outpatient Complex Imaging are subject to the deductible and are then paid at 80%. Important to note is that complex imaging such as CT scans or MRI’s are subject to pre-authorization which should be done by the ordering physician; however, never assume it has been done. Check with the imaging facility BEFORE you show up for your appointment. Also, it is always a good idea to use freestanding facilities versus a hospital for these services to keep costs down for you and the plan.]


  1. Urgent Care – $15 copay
  2. Routine Eye and Hearing Exams 100% covered
  3. $5000 every three years for Hearing Aids (some members were extremely unhappy with this)
  4. 24-hour Nurse Line, Annual Nurse Home Visit (evaluates home safety, how you take your meds, etc) Completely voluntary. You don’t have to do this if you don’t want to.
  5. Healthy Rewards – You get a gift card if you do preventive and/or wellness things.


  1. You still pay monthly Medicare and UAL premiums for coverage, just as you do now. The latter may be lower than current premiums.


[Just a housekeeping note here: If you are enrolled in Medicare Part B the premiums are based on income thresholds and the base rate rises each year. The new premiums have not yet been released but you can find them when they are announced at www.Medicare.gov.


There can be a load called IRMAA – Income Related Monthly Adjustment Amount to the Medicare Part B premiums determined by your reported income to the IRS from 2 years prior. If you have had a significant change in your income causing you to fall below the threshold you can appeal it by contacting Social Security at 800-772-1213 or visit www.socialsecurity.gov.]


  1. Chiropractic coverage will include “enhancements,” meaning heat/cold and/or electro-stim treatments. I didn’t get to ask for more detail on this, but I will look though what came in the mail and/or call the new, dedicated phone line. There will be No limit on number of visits.


[Details of this nature are typically addressed in a document called “Evidence of Coverage” which I have already requested; however, it is not yet available. Hopefully this will be provided PRIOR to open enrollment.]


  1. If you have to go to the hospital in a non-emergency situation, you get transport to and from, 24 “legs” a year. You also get coverage for an ambulance, if needed. After you return home, you can have two meals a day (up to 14 total) delivered right to your home.
  2. Our prescription drug coverage will be though Silver Scripts, which is a division of CVS.
  3. If you only want Traditional Medicare and not this plan, there is also a drug plan only.


[Traditional/Original Medicare enables you to purchase a Medigap plan to pick up the some of the cost sharing toward medical expenses and there are a multitude of carriers that offer them, including other Medicare Advantage Plans (Medicare Part C). There are also many carriers that offer Medicare Part D (drug plans). You will find that the SilverScript plans UAL is offering are very rich compared to anything you can buy in the market. If you terminate your coverage with UAL, in order to exercise you Guarantee Issue Rights for a Medigap plan to supplement Original Medicare you have 63 days in which to apply from the date you lose coverage under the current plan. Insurance carriers will ask for a letter reflecting your termination date. You will also need a Notice of Creditable Coverage (recently mailed) in order to avoid a premium penalty for Medicare Part D if you don’t want the UAL Drug Only Plan. If you do not apply before this 63 day period ends, you can be medically underwritten, rated up or declined. You would still be able to maintain original Medicare Parts A & B and pay the Part B premium; however, it’s not a good idea to leave yourself exposed to the liability. Lastly, make note of the additional benefits UAL has plugged in that original Medicare does not provide. As I understand it from several sources specializing in Medicare plans, the 12 month period in which you are first enrolled in a Medicare Advantage Plan enabling you to bail out and go back to Original Medicare and get Guarantee Issue Rights for a Medigap (Supplement) plan DOES NOT APPLY. This is an important note if you were thinking about enrolling in the UAL Plan to try it out and then change your mind a few months later and want original Medicare back with the idea of buying a Medigap plan. You can terminate the UAL plan at any time and get back Original Medicare, but, you may not be able to purchase a Medigap plan without medical underwriting or a premium load or be declined. Some States may have more lenient laws allowing this. You can check your State Insurance Administration Consumer web site or speak with an insurance broker in your State.]


The following were answers to questions –

  1. Are premiums based on age and/or your location? NO
  2. Is United offering any other plans? NO, unless you’re in an HMO. You can choose to remain in that.
  3. Can the terms and premiums be changed at Aetna’s discretion? The answer I got was NO. I think that’s because it’s a United custom plan.


[All group plan rates are subject to change; however, annual rate guarantees are standard fare. Just as rate changes happened under the current plan, they can likely change in the future. If you purchased a plan in the open market, they are most often age rated so as you age, the rates rise in addition to any across the board increases for the carrier. United Healthcare through AARP is community rated so there are no age rates to blow through; however, they can raise rates on everyone enrolled in their plans. It’s a mixed bag out there.]


  1. Are you covered out of the US? YES, but for Emergency and Urgent Care only.
  2. What is the Silver Scripts prescription OOP max? $300, which does not go toward the $1200 plan OOP. I have major doubts about this one, and asked it again, but they insisted that’s correct.


[I believe when the plans were designed they wanted to match the old plan as closely as possible which had a $250 deductible and a $1,500 OOP. I have confirmed the OOP for the pharmacy does not apply to the $1,200 medical OOP. They are totally separate. Further, the $300 OOP on SilverScripts applies only to RETAIL purchases for a 34 day supply. See details on page 5 of the white SilverScripts Summary of Benefits. Everyone should look at the formulary of covered drugs to see where their prescriptions fall and use Preferred Pharmacy benefits for the lowest costs. If for some reason your drug is not covered, this web site provides the greatest discounts I have found and you can use them for pet meds as well: www.pharmacychecker.com]


  1. What about providers that don’t accept Medicare? They said that there are three situations, ie providers that ACCEPT Medicare, those that PARTICIPATE in Medicare, and another one I didn’t get to write down. They said that usually covers most providers, but I also have major doubts about this.


[The other category is providers that Opt-Out of Medicare. Typically these are providers that don’t accept any insurance and expect you to pay billed charges. It can be expensive to go this route and there are many providers in this category, typically, primary care and psychiatry in our local market. We call them the outliers. There are also physician practices providing Direct Primary Care where you pay a flat dollar amount each month or an annual fee for specific services with a promise to see you whenever necessary. These arrangements are growing in number especially in the Mid-West and West Coast. These practices may or may not not accept Medicare or Aetna.


When I spoke with Aetna about determining if a provider accepted the plan it is highly recommended you speak with the provider BILLING office and ask if they are willing to bill Aetna directly. The front desk folks might give you incorrect information and the billing office knows exactly what they are willing to do. Ask if they will accept the Medicare Allowed Amount. Never trust the Aetna web site regarding the status of your provider. Call and ask specifically about your provider. Aetna has two data bases and one can say yes and the other says no for the same doctor. Aetna is also willing to reach out to your hospitals & doctors on your behalf.]


  1. I asked, “What about when you go to the ER, where you have no idea what providers you’ll get and whether they all accept Medicare. The answer was the all hospitals accept Medicare, and their providers, like anesthesiologists, pathologists, lab techs, etc, have to abide by the hospital policy. I also have major doubts about this.


[I made a call to the billing department of our local hospital and they confirmed that all ancillary providers that bill for hospital rendered services accept Aetna Medicare Advantage. Check with your favorite facility and talk to the folks in billing.]


  1. Someone asked about being able to leave after 12 months and whether you could return to this UAL coverage. Medicare, on page 72 of “Medicare and You,” says you can’t return to traditional Medicare if 12 months have gone by and you haven’t returned. They said that since this is a custom employer-sponsored plan, that doesn’t apply. As long as you have “credible” coverage you can opt back in through United’s Your Benefits Resource (YBR).


[You can purchase a Medigap plan (Guarantee Issue Rights) within 63 days from losing the current group plan. The 12 month trial period only applies to Medicare Advantage Plans purchased in the individual market. The UAL plan is a group plan. Here’s the link to the citation of rules from the Medicare web site. Click on the second bullet point and then read the second heading in BOLD. From what I am told, we do not qualify for the “certain circumstances” in the light blue box at the bottom. https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/guaranteed-issue-rights


If anyone has questions about getting Original Medicare back and leaving UAL they should confirm everything by making their own calls to Medicare and UAL benefits department.


One last answer to a question posed regarding spouses. If the UAL employee dies leaving a spouse that was covered by the plan, the spouse may continue the Aetna Medicare Advantage Plan at the single rate charged.


Once you terminate the UAL retiree plan you may not enroll again during subsequent open enrollments per the UAL Benefits Department.


I suppose there could be an exception if you are retired and your spouse covers you under their group plan while an active employee of another company. I quick call to the UAL benefits department can answer that question. So many scenarios and so little time.]


If I were the consultant for UAL this roll out would have been announced 6 months in advance and I would have engaged Medicare specialists to attend every meeting well in advance of open enrollment. Thankfully, the SilverScripts coverage is better in my humble opinion than any other Medicare Part D plans out there. For anyone with multiple drugs or expensive drugs like biologicals and immunotherapy the jury is still out because we just don’t have the pertinent details. A $48 copay doesn’t sound like much; however, once you hit the catastrophic level and you take a $15K a month drug like Tagrisso, the 5% could be $750 a month for a 30 day supply. Specialty drugs are a huge driver of benefit costs today. I have reviewed the formulary at the SilverScripts web site but the Summary of Benefits we received under PLEASE NOTE on page 5 indicates the SilverScript formularies do not include any drugs that may be available to you through the additional coverage provided by United Airlines. I guess you just have to call and ask if your expensive drug is covered and at what cost to you if you don’t see it on the formulary.

I look forward to posing more questions to the Aetna team on October 18th.

And the latest from her has a good explanation about the prescription drug OOP:


The Out-of-Pocket expense limit applies to retail purchases only for what I call emergent medications like an antibiotic for bronchitis, etc. Typically these are short term medications and the $100 deductible applies and then you pay 20% of the total cost of the drug regardless of whether it is a generic, Preferred Brand or Non-Preferred Brand name drug until you have paid $300 OOP. I use an inhaler that costs about $450 a month for a Preferred Brand name drug. If I had it filled each month I would be paying $90 a month after my deductible until I spent $300. That would occur by month 3. I wouldn’t do that because by getting a 90 day supply I only get my wallet out 4 times during the year paying $48 for a 90 day supply or $192 out of my pocket by using mail order. Stage 3 of the plan is called the coverage gap or donut hole. Under plans sold in the market you pay more for drugs in this stage; however, United has extended coverage for this gap so you don’t pay more than the co-pay, provided you use mail order. Again, keep in mind emergent medications are needed immediately so you would likely go buy it at a pharmacy and pay your deductible if it hasn’t been met previously, and then pay 20% of the cost of the drug. That’s where the $300 OOP comes in. There are some very expensive drugs out there, so in the end, it depends on what you are taking and how often. I’d rather get my drugs by mail and spread the expense over the year instead of “eating it” in the first quarter and paying more.


Stage 4: Catastrophic Coverage – think of all your prescription costs, what you pay either at a retail pharmacy or mail order, dropping all those copayments into a bucket for each patient under the plan. When that amount hits $6,350 you then will pay the greater of 5% of the cost of the drug or $3.60 for generics or $8.95 for preferred or non-preferred brand name drugs. This is the best I can ascertain from the information they sent in the 2020 Benefits Enrollment Guide. Specialty drugs have different copays which are shown in the chart.


I didn’t say this plan was better than what we have right now. I said this plan through SilverScripts is better than what you can purchase in the open market. If you were to go on the Medicare.gov web site and compare what you have to pay in all 4 levels under Medicare Part D with other plans you will find your costs much higher because of Stage 3 (donut hole) which United addressed by just keeping the copays. When I got the materials I went in to look at other pharmacy plans offered by SilverScripts and other Pharmacy Benefit Managers and the new United Plan is better, but, not necessarily better than what we had. Under the old plan the OOP was combined for medical and drug and was capped at $1,500 a year. So, if you had a hospital stay or other expenses and met that OOP your drugs didn’t cost you anything. My OOP costs on the best SilverScripts plan offered in the open market was about $5K-$6K a year but with the United Plan it’s only $192. Huge difference.


I hope this helps.