Phil Castell
Castell Insurance
426 E. Washington St., Sequim, WA 98382
Phone: 360-683-9284 • Fax: 360-683-9026
Phil@CastellInsurance.com
www.CastellInsurance.com  

 

Well folks, I can guarantee you one thing: This definitely will be my last article for 2009, and who knows what wonderful changes in health care will be occurring in 2010 and beyond.

I have had phone calls from a couple of insurance companies that did not particularly appreciate some of my earlier comments, but as I am writing this column as a freelance journalist and my comments were accurate, there was not much they could do. I consider this to be a duty to make the public aware of some of the little surprises that can be hidden in fine print for the unwary.

As I write this on the morning before Turkey Day, I thought I would share a few observations from the past 10 days since Medicare Part D open season got under way in full force.

One of last year's most popular Part D plans has changed quite drastically and frequently not for the better.



38 percent increase

The plan is the Coventry AdvantraRx Value plan, which went from a monthly premium of $21.60 to $29.90, an increase of 38 percent. In addition, they introduced a $100 deductible for that plan.

But wait, that is not all. They altered the co-pays on the nongeneric drugs from a fixed dollar to a percentage of the retail price of the drug. For example, a Tier 2 drug went from a flat co-pay of $30 to a co-pay of 18 percent. For many drugs this will mean a lower co-pay, which is a good thing.

However, on a Tier 3 drug that in 2009 had a $50 co-pay, for 2010 that will change to 65-percent co-pay. Let me tell you,

Tier 3 drugs are Tier 3 drugs because they are expensive.

For example, I have two sisters who are policyholders in Port Townsend. One mailed me her list of medications and she took a drug called Femara, which according to www.Medicare.gov has a retail price per month of $374.64.

If she stays on the Coventry AdvantraRx Value plan, her monthly co-pay would be $243.52 just for that one medication. With another program, her co-pay would be only $30.

Her sister was on a medication that had been deleted from the formulary for 2010. If she had not taken five minutes to look her drugs up in the formulary and call us, she would have been paying the full price of the drug all year.



Where's the advantage?

Let's take a moment and chat about Medicare Advantage Plans, as they are not immune from having faults. My personal peeve is the plans (and agents who represent them) that do not have a maximum on what your out-of-pocket expenses will be if you ever get sick.

Sterling Healthcare has four plans in Clallam County, two without Rx coverage at $39 and $59, and two with Rx coverage at $99 and $119. I find it strange that the lowest-priced and the highest-priced plans have a cap on what your out-of-pocket expenses will be, while the middle two plans do not.

Secure Horizons from United Healthcare has canceled its 2009 Plan 53 and replaced it with the "similar" Plan 59 for 2010. The plans are similar in many respects until it comes to the maximum out of pocket. 2009 had a maximum of $3,350 and 2010 has no maximum.



Being maxed out

These plans without maximums are, in my opinion, a dangerous time bomb waiting to explode. Let me explain.

Most people have insurance for the big "what if" as opposed to the routine small items and if the "what if" isn't covered, well, you can figure that out for yourself.

A woman called my office yesterday who had just been sold a plan with no maximum on what her co-pays might be. She recently has been diagnosed with cancer.

If she stays with that plan for 2010, where she is responsible for 20 percent of all outpatient services, I dread to think of her exposure. If she had to go for chemo for five days a week for five weeks, that is a huge bill and even 20 percent of that bill is a very large amount.



Group Health group

Let's talk about Group Health. They have been holding lots of great seminars in the area and have inserts in most newspapers. Their list of "in network" providers is quite small, but they will cover "out of network," albeit with a higher co-pay for you, the patient.

What I do not think many doctors or clinics are aware of is that they can accept Group Health like another type of Medicare Advantage Plan and be reimbursed at the same Medicare rates, without the need of contracting.

So, if the Group Health plan looks attractive to you, ask if your provider will accept them on an "out of network" basis. The provider will get paid the same; it is just that a higher percentage will be from your pocket.

A couple of doctors' offices have told me they really do not want to contract with any Medicare Advantage plans. Well, I believe that may be necessary for 2011 as further changes will be occurring in this marketplace.

And finally, the Essence Plan that has been highly advertised on Seattle area TV stations is not available here on the peninsula.

We recommend you seek help navigating this maze. The great folks at SHIBA can be reached at 452-3221 or 800-Medicare (800-633-4227) is another great resource.

As the old desk sergeant in the TV show "Hill Street Blues" always said, "Be careful out there."



Phil Castell is an independent insurance agent in

Sequim. He can be reached at 683-9284 or PhilCastell@msn.com.