I'm wrapping up my first week of taking calls for an insurance company that provides Medicare Advantage plans. I've taken a wide range of calls about a variety of issues and answered many different questions, and the worst conversations, by far, always begin with "I went to pick up this prescription I need and it cost me so much more! What's going on?"
I check their claims, their coverage, their benefits. I wince when I see scripts jump in price, sometimes doubling, tripling, even quadrupling into three digits. These Medicare members have worked hard, they pay their premiums on time, and they expect to have a certain amount of coverage. What they do not expect is for their prescription prices to skyrocket out of nowhere. And I hate being the person who says, "Well, I see you're in the coverage gap."
"What does that mean?" The inevitable follow-up question.
"It means you'll be responsible for 84% of generic scripts and about 55% of brand name medication....if those brands are preferred."
"Why?"
"Because that's how Medicare Part D works."
Medicare Part D is so obviously the result of Republican "genius." And they are responsible for another $2400 before "Catastrophic phase" kicks in. Catastrophic. I hate everything about that word. I've been thinking for seven weeks about how much I hate that word for that phase, and even now, I have a hard time articulating why...I have a hard time "unpacking" everything that bugs me about it.
Hand in hand with that is the explanation that their premiums and their previously met deductible has nothing to do with the coverage gap. They are shelling out money every month for coverage that doesn't cover anything. Many of the seniors I've talked to can barely afford those premiums, but they can't simply drop the coverage. Because if they drop Part D and they don't enroll in a similar plan with creditable coverage, they can't re-enroll without being assessed a Late Enrollment Penalty. And that penalty will be assessed every month for the rest of their lives.
Hmm, a penalty for not participating in a federally supported insurance plan? Where have I heard that before? Why did nobody point out that Part D is in effect the same as the ACA mandate? Did it occur to nobody that the GOP already floated the test balloon for this plan? Obama was always confident the ACA would survive the Supreme Court, and my guess is that's because Medicare Part D and mandatory drug coverage has already been the law of the land for the past six years.
But I digress.
The real point is, we need to boost the signal on the relationship between ACA and Part D's coverage gap. I've heard Obama mention it, but why aren't there ads? Why isn't there a concerted effort to reach out to the senior citizen community and explain that Obamacare is going to eliminate the absolutely most frustrating part of Medicare? Given the number I've talked to who don't even understand what it is and how it's impacting them right now, how many seniors are likely to know the details of how it will change? Of how it will improve?
I talked to a member today who had a $250 copay for her arthritis medication. The only medication that has brought her any relief. She lives in Florida. She sounded genuinely upset about this, genuinely frightened that she will have to drop this prescription, especially since she's tried others before this one and she knows they don't work. How is that right? How could anybody feel good about that? How could the GOP rail against somebody's grandmother finding relief from a debilitating condition? Some members choose to pay even more monthly in order to get supplemental insurance....but what about the ones who already live on a fixed income?
Somebody else asked me today if there's any help available for meeting the costs of his prescriptions. They totaled nearly $600. Do you know what the solution is? Ordering 90 days worth through a mail-order pharmacy because if you can afford to shell out $800 on a single medication, all at once, you'll save $25-$30 overall. There is no other help, though the SSA does grant some people a Low-Income Subsidy. But there are plenty of members who are getting by...until something terrible happens and suddenly they're filling scripts so expensive they leap right out of initial coverage phase and into the coverage gap.
Sometimes the manufacturer's deign to sell their medications at cost to those who can demonstrate "real need." But in this economy, many have a "real need" that will never be recognized.
I hate explaining the coverage gap. I'm so happy I can assure them that the hit will be a little less painful next year, and a little less painful the year after that. But 2020 is a long time from now, and for many seniors, that's too late. Seniors are supposed to be the GOP's to lose. Why? Why would they support a party that wants to fuck them coming and going?
I don't know if Obama's solution to this problem is perfect. I don't even fully understand why the coverage gap has to exist. Why do we declare open season on seniors? Why do we let the pharmaceutical companies fill their coffers with the money they fleece from people who have worked hard, who have raised families, who are dealing with conditions that they couldn't have foreseen? Or conditions they couldn't have avoided even if they saw the warning signs years ahead?
"Why do I even have insurance then?" One irate man asked me today.
The question stumped me. It was the same question I asked my instructor in training. He didn't have an answer. God knows I don't. But we need to work harder to get the word out that there's a change coming. A change that every single one of us will be thankful for...a change that's happening right now, though much too slowly for the people I talked to today. Not to mention the people I will talk to tomorrow. And all the ones I will talk to as the year winds down and people inch closer and closer to the edge until they fall straight down in that hole.
The "donut hole" is a cute misnomer. For some members, it's a black abyss that there is no relief from. What do they do when they have to choose between their prescriptions and buying food? What will they do if Romney wins and makes good on his promise to repeal Obamacare? To end Medicare?
What will you do?
10:29 PM PT: Wow, in the time it took me to drink a beer and sing "I've Just Seen a Face" and "Ticket to Ride" at the bar, the diary appears to have risen and fallen from the recommended list. Far out.
There was a request for an explanation of the donut hole in the comments. Basically, Medicare Part D is the prescription drug coverage program. When you become eligible for Medicare, you have a total of six months to enroll yourself. If you don't, you have to present proof of "creditable coverage" and the $4 wal-mart plan doesn't count. If you don't do either of those things, you will automatically be assessed a Late Enrollment Penalty. When you sign on later because suddenly you're sick and you'll need help with the coverage (it's not like they can deny you after all!) you will have to pay a LEP based on a calculation (I think it's 1% of the average...premium?) forever after. Medicare D has 4 stages: deductible, initial coverage, coverage gap, catastrophic.
In the deductible phase, you are responsible for the full out-of-pocket-cost plus your monthly premium. I spoke to a gentleman today who had a $320 deductible for the year. He paid something like $15/month on his premium, but he never got sick all year. Now he had surgery on his knee and suddenly he has a prescription to fill. One that came to $140 because he hadn't met his deductible and he was responsible for the cost. Consider he already spent $150 on premiums, and that one prescription may cost him $300--he doesn't think he'll meet his deductible this year.
After the deductible is initial coverage. That's when the coverage kicks in and you are only responsible for the co-pay/coinsurance. For many generic scripts, the copay is $0 or at least than $10. That goes up, and for tier 3 and tier 4 it's usually something like 33% coinsurance. The drugs that aren't covered on the formulary can get physician authorizations, and they're covered as tier 4 so the speciality and brand name drugs are very expensive, even with coverage. I spoke to a lady who need a 30 day supply for a drug that cost $888...her responsibility was a little over $400. And she's still in initial coverage.
Once that hits 2,930, the insurance company steps back and says "K, now you got this."This is calculated by the FULL cost of the drug, not the member's responsibility. So if you have to take a year's worth of a drug that costs $800, by April you'll be in the coverage gap, even if your out of pocket cost is only a total of $1600.
Then there's the coverage gap. Due to Obamacare, the coverage gap isn't quite so bad this year. Generic drugs have a 14% discount, and brand names are around 55% off. Pharmaceuticals who wouldn't agree to this discount were informed by the Center for Medicare/Medicaid Services they were no longer welcome on Medicare formularies. But some brands are very expensive and don't have generic options.
Here's the trick, though. Remember how in IC it was total drug cost? In the coverage gap, it's only out of pocket costs. So when they calculate the $4700, they count the $200 you might have been paying while you were in IC. So that's $800 Out-of-Pocket for you...you still have to pay $3900 before you hit catastrophic. Even though on the surface it looks like the difference between $2930 and $4700 is a little less than $2000.
Then you hit catastrophic. That's when the insurance company basically stops keeping track. From there on, all scripts, all tiers are 5%. But it's possible to get into the coverage gap early and then stay there for the rest of the year--while you're still paying your premiums and you are essentially locked into the plan. You can't decide "I can't afford these premiums for the rest of the year, I'll just enroll for the next year" because if you do that, you will literally pay for it.