Something New for Those Using Insulin: Part D Senior Savings Model

Starting in 2021 there is a new program for Medicare beneficiaries that use insulin. I have pulled this information from CMS.gov.

CMS’s Part D Senior Savings Model is designed to address President Trump’s promise to lower prescription drug costs and provide Medicare patients with new choices of Part D plans that offer insulin at an affordable and predictable cost where a month’s supply of a broad set of plan-formulary insulins costs no more than $35 each.

The idea here is that the user of insulin would pay no more than $35 per month for each insulin that he/she uses. Costs such as the deductible and the coverage gap (doughnut hole) will not apply

CMS is testing a change to the Medicare Coverage Gap Discount Program (the “discount program”) to allow Part D sponsors, through eligible enhanced alternative plans, to offer a Part D benefit design that includes predictable copays in the deductible, initial coverage, and coverage gap phases by offering supplemental benefits that apply after manufacturers provide a discounted price for a broad range of insulins included in the Model.

The Model aims to reduce Medicare expenditures while preserving or enhancing quality of care for beneficiaries, and to provide beneficiaries with additional Part D plan choices, both for beneficiaries who receive Part D coverage through standalone Prescription Drug plans (PDPs) and those who receive Part D coverage through Medicare Advantage, Prescription Drug plans (MA-PDs). These Model-participating plan benefit packages (PBPs) will provide stable, predictable copays for certain insulins that beneficiaries need throughout the different phases of the Part D benefit.

The article lists the participating pharmaceutical manufacturers.

  • Eli Lilly and Company
  • Novo Nordisk, Inc. and Novo Nordisk Pharma, Inc.
  • Sanofi-Aventis U.S. LLC

Please click here to bring up a list of the insulin brands available for the Senior Savings model.

The CMS article also recommends the use of Medicare.gov for finding plans that are participating in the program.

To pull up a 50-state, complete list of participating prescription drug plans (PDPs) and Medicare advantage (MA) plans, please click here.

The upshot of all of this is that you should have us shop your prescriptions on Medicare.gov, especially if you are using insulin, pens or vials. To do this, please use PDPHelper.com to send us a list of your prescriptions, and we’ll take it from there. End

Medicare Advantage and MSA Plan News

Medicare Advantage (HMO & PPO) Plans

In general, we have noticed that the premiums have remained about the same. Be sure to look over your Annual Notice of Change (ANOC). Most companies will give you a side by side comparison of 2020 and 2021 benefits. Some plans have increased a few dollars and others have had minimal decreases.

Various plans have increased their offerings of dental, so be sure to see what benefits your plan offers. Some plans offer an optional supplemental benefits package in the $25-30 monthly premium range. These packages usually include dental, vision, and hearing benefits.

One company had a $50 copay for joining Silver and Fit. They have dropped that for 2021. Some plans now include a meals benefit after a hospital discharge. Again, be sure to consult your ANOC for specifics.

Medical Savings Account (MSA) – a different type of Medicare Advantage Plan

What are MSA plans and how to do they work?

An MSA is a high-deductible health insurance plan combined with a savings account that you can use to pay for your health care costs. Since this is a type of Medicare plan, Medicare provides the funding.

Medicare.gov has a handy 10 step breakdown of how MSAs work.

  1. Choose and join a high-deductible Medicare MSA Plan.
  2. You set up an MSA with a bank the plan selects.
  3. Medicare gives the plan an amount of money each year for your health care.
  4. The plan deposits some money into your account.
  5. You can use the money in your account to pay your health care costs, including health care costs that aren’t covered by Medicare. When you use account money for Medicare-covered Part A and Part B services, it counts towards your plan’s deductible.
  6. If you use all of the money in your account and you have additional health care costs, you’ll have to pay for your Medicare-covered services out-of-pocket until you reach your plan’s deductible.
  7. During the time you’re paying out-of-pocket for services before the deductible is met, doctors and other providers can’t charge you more than the Medicare-approved amount.
  8. After you reach your deductible, your plan will cover your Medicare-covered services. Read information from the plan for details about out-of-pocket costs.
  9. Money left in your account at the end of the year stays in the account and may be used for health care costs in future years.
  10. If you use funds from your account, you must include this special form [PDF, 89.4 KB] with information on how you used your account money when you file taxes. http://www.irs.gov/pub/irs-pdf/f8853.pdf

The available states in the West are now MT, WY, UT, AZ, NV, NM, and OR. Unfortunately, MSA plans are currently not available in WA, ID, CA, and CO.

How MSA plans work

When you see your medical provider, you present your MSA ID card to your provider’s billing office. The provider bills the MSA plan. The bill comes back to you, and you pay you provider from your debit card account. Meanwhile, the MSA plan applies that amount to your deductible. Never pay your provider prior to them billing the MSA plan.

MSA plans do not provide prescription drug coverage. Medicare beneficiaries who are enrolled in an MSA plan and who also wish to have drug coverage, will need to enroll in a stand-alone Part D prescription drug plan.

FAQ’s

Q: Where do MSA plans get the money to set up my debit card account?

A: Remember, Medicare advantage (MA) plans are privatized Medicare plans. Let’s say that an MA plan without Rx coverage receives around $800 per person per month from Medicare to provide your health coverage. Out of that, MSA plans can fund your debit card account.

Q: Let’s say I spend $500 on doctor bills for 2021, what happens to the $1,500 still remaining in my debit card account?

A: Your unused funds rollover and will be available for a future year. This is not a “use it or lose it” deal. If you don’t use it, it rolls over.

Q: What happens if I exhaust my debit card account and still have more medical bills?

A: Your responsibility is to cover your bills until you reach your deductible. Once you have met your deductible, your MSA plan pays 100% of your Medicare approved expenses for the remainder of the year.

Q: What about networks. Am I restricted to a doctor network?

A: There are no networks with MSA plans. Most any provider that works with Medicare should be willing to accept your MSA plan. That’s great news for snowbirds or those who travel to other states.

Q: What about preventative checkups? How are they covered?

A: Unlike other Medicare advantage plans, there are no, zero copay physicals or other preventative services. Your provider will bill the plan, and then you’ll pay your physician from your debit card account.

Q: Can I use my MSA funds to pay for vision or dental services?

A: Yes. In addition, you can also use your MSA account for hearing aids, hearing aid batteries, prescription copays, and long-term care expenses. Please note: Using money in your account to pay for health care costs that aren’t covered by Medicare will not count toward your MSA plan’s deductible.

Q: Who can enroll in an MSA plan?

A: Most people who are on Medicare Parts A and B and reside in a state where an MSA plan is offered are eligible to sign up. You will need to decide if the program is right for you. There are some people that are ineligible to enroll in the MSA program. These exceptions primarily are those receiving VA or Medicaid benefits.

The following are some of the reasons why Medicare beneficiaries have enrolled in an MSA program.

  • Those that like the idea of a no premium plan.
  • Those that live in a county where no other Medicare advantage (MA) plans are offered. Many of the sparsely populated counties of Montana, Wyoming, and Oregon have no other MA plans to choose from.
  • Those that do little or infrequent doctoring.
  • Those that like the idea of having funds available for dental or vision.
  • Those that prefer to have their own standalone Part D Prescription (PDP) plan.
  • Those who are looking for an alternative to their Medicare supplement plan and don’t want or can’t get a standard HMO or PPO Medicare Advantage plan.

Important Information for Existing MSA plan Members

If you are already a member of an MSA plan, your membership for 2021 will automatically renew. Be sure to read your annual notice of change to keep informed of any changes to your plan. The MSA company is also offering a second version of their plan with a larger debit deposit and a larger deductible. Please contact us for details.

Conclusion

Please contact us with questions about this MSA plan or your interest in any other Medicare advantage plan. There are some situations where a switch to the MSA plan may be a good fit for your situation. Here are some examples.

Case #1: Alice is in her 90s and is on an old Plan F with a premium of over $300 per month. She has a medical condition which makes it difficult for her to switch to another Medicare supplement plan. She lives in a sparsely populated county that has no other Medicare advantage plans. He out-of-pocket will hundreds of dollars less than the annual $3,600 Medsupp premium.

Case #2: Martha has Medicare supplement Plan L. Since there is a fair amount of cost-sharing with Plan L, the maximum circuit breaker limit rises to $3,110 in 2021. By the time she adds in her annual premium for Plan L and her cost-sharing, she could be out hundreds more with Plan L compared to the MSA plan.

Case #3: Bill has Medicare supplement Plan K. In 2020 his circuit breaker limit is $6,220. That’s more than double of what him maximum out-of-pocket would be with the MSA plan.

Case # 4: Shirley’s Plan F has climbed to $200 monthly, and she would like to shop for a lower cost Medsupp. Unfortunately, she has a COPD diagnosis making it impossible for her to switch to a lower cost Medsupp. The MSA plan may be a good alternative for her. There is no medical underwriting.

Please contact us for complete details to see if the MSA plan is a good fit for you. End

PDP Helper Tips

This 2020 AEP is our fifth year of using PDPHelper.com. The following are some tips to help us do an accurate search on your behalf for your 2021 Prescription Drug Plan (PDP). Our goal is to recommend the PDP that will be most suitable for you.

Step 1

Please enter your name, phone, email address, your zip code, and your county of residence. Some zip codes span multiple counties, and that’s why we request your county of residence. This means where your residence sits.

Next, please list your top pharmacy choices. We also ask you if you would be willing to use Walmart, Walgreens, or a mail order pharmacy if that will save you money.

Step 2

In this section, only enter your pills, capsules, or tablets. Liquids, gels, creams, insulin, eye drops, patches, etc. are in the next steps.

Enter the name of your prescription, the dose, and the quantity you buy. Important, is the quantity you buy per one month, per every two months, per every three months, or per every twelve months? If you take something as needed, estimate how many pills you buy and how often you buy it. Your estimate does need to be exact. Just get it as reasonably close as you can.

Example #1—Betty take two, 500mg metformin tablets every day. She buys 60 every month.

Name of Prescription: Metformin
Dosage: Enter 500mg
Quantity: Enter 60
Frequency: Enter month

Example #2—John take hydrocodone/apap, 325/10mg, as needed for back pain. Some days he takes none but other days he takes two or three. He estimates he takes around 45 per month

Name of Prescription: Hydrocodone/apap
Dosage: Enter 325/10mg
Quantity: Enter 45
Frequency: Enter month

Step 3

The section is for Insulin, Inhalers and Nebulizers

Example #3—Alice uses insulin. She checks “yes”. She enters her information as follows:

Name of insulin: Lantus Solostar pens
Size: 3 mL
Quantity: 5 pack or just 5
Frequency: per 2 months

Example #4—Shirley uses Advair. She checks “yes” for the category: “Do you use any inhalers or nebulizers?” She enters her information as follows:

Name of inhaler: Advair
Size: 250/50
Quantity: 1
Frequency: 1 month

Step 4

This final step is for Eye Drops. Gels, Creams, Lotions or Salves, and Other Prescriptions.

Example #5—Mary uses eye drops. She checks “yes” for this category and fills in her information. Please do NOT attempt to say “2 drops per eye each day.” We need to know the size of the bottle, usually 2.5 mL, 5 mL, or 10 mL and how often you fill your prescription.

Name of eye drops: Latanoprost SOL 0.005%
Size: 2.5 mL
Quantity: 1
Frequency: 1 month

When finished, please hit the submit button. Thank you in advance for using PDPhelper.com. End