A question for retired state employees. (health insurance, how much, pharmacy)

[dutchman09]

Has anyone noticed a change in copays for visiting a specialist? What used to be paid by a secondary Health Insurance Company, after Medicare, is now listed as "patients obligation". It seems the ADOA inserted a clause called "Non-duplication coordination of benefits with Medicare" in their new contracts with health insurance companies as of 10/01/09. After many phone calls I am still not able to find out exactly what that clause means. The closest I've come to an explanation was if Medicare pays 80% for a specialist office visit the remainder is my responsibility. Any enlightenment into this situation would be greatly appreciated.

[SouthernBelleInUtah]

Are you on an Advantage-type plan? Or straight Part A and B with a SUpplement? IS this a state-funded plan pecular to AZ state employees?

[dutchman09]

Originally Posted by SouthernBelleInUtah

Are you on an Advantage-type plan? Or straight Part A and B with a SUpplement? IS this a state-funded plan pecular to AZ state employees?

Yes, this is a state-funded plan peculiar to Az state employees. I have Medicare part A & B as my primary and United Health Care as my secondary. Up until October '09 UHC would pick up what Medicare's 80% did not cover. But from what I found out ADOA (Arizona Department of Administration) added this clause "Non-duplication coordination of benefits with Medicare" to persuade UHC to stay within Arizona (because in August they were not one of the companies offered for open enrollment and in September there was an amendment sent to everyone which all of a sudden included UHC). I wish I was wrong, but to me it seems as though ADOA sold out the retired Arizona State Employees for a commission! If someone can prove different, your welcome. I've made numerous phone calls on this subject and have been given the 'traditional' run around. No one could or would explain the meaning of the clause "Non-duplication coordination of benefits with Medicare".

[observer53]

The late addition of UHC was due to a bid protest BY UHC, so I don't think ADOA was trying to "persuade UHC to stay in AZ". I'm an active state employee, so I don't have the same situation as you, (we all had changes in copays and all that, too) but I'm surprised (or maybe not, now that I think more about it ) that no one at the Benefits office or at UHC could explain what that phrase means.

There were changes in a lot of the coverages, as I said, but I don't think ADOA "sold out" the retirees in this case.

[observer53]

When I Google that phrase, I find, among other things, this definition:

"Requirement that the combination of Medicare and the employer's plan can not be greater than the amount the employer's plan would pay without Medicare."

[dutchman09]

Originally Posted by observer53

When I Google that phrase, I find, among other things, this definition:

"Requirement that the combination of Medicare and the employer's plan can not be greater than the amount the employer's plan would pay without Medicare."

Before I joined Medicare I always had an office copay. Since September of 2005, Medicare paid 80% and my secondary insurance (UHC) paid the rest. In October of last year this changed. Example:

For an outpatient office visit (to which I have gone since 2004) Medicare paid 80% which amounted to $62.03. According to the bill, my charges for this one item was $15.51 of which UHC paid $2.94. Where is the duplication? This was one item of several on the bill. UHC paid $0.00 on the other items. Where is the duplication?

I have since called UHC and they agreed to "resubmit this bill for further consideration." Results in 10 days. Not only did the doctor whose bill this was ask me to fax it to him, but two other doctors stated that "if you pay for two insurance's you should not have a copay." UHC is not a supplement insurance. Why does the state flat out refuse/avoid any explanation of this?

[observer53]

Originally Posted by dutchman09

Before I joined Medicare I always had an office copay. Since September of 2005, Medicare paid 80% and my secondary insurance (UHC) paid the rest. In October of last year this changed. Example:

For an outpatient office visit (to which I have gone since 2004) Medicare paid 80% which amounted to $62.03. According to the bill, my charges for this one item was $15.51 of which UHC paid $2.94. Where is the duplication? This was one item of several on the bill. UHC paid $0.00 on the other items. Where is the duplication?

I have since called UHC and they agreed to "resubmit this bill for further consideration." Results in 10 days. Not only did the doctor whose bill this was ask me to fax it to him, but two other doctors stated that "if you pay for two insurance's you should not have a copay." UHC is not a supplement insurance. Why does the state flat out refuse/avoid any explanation of this?

Have you talked to the Benefits people at DOA about this, or just UHC. If so, what did they tell you?

[dutchman09]

I have called DOA on several occasions. I was told:
Call UHC (who told me to call DOA)
Call Medicare (who couldn't tell me how much they paid toward the bill.)
It's being researched (two weeks)
If Medicare pays 80% UHC does not have to pay
The balance is your responsibility (no explanation)
and best of all........."It's a mistake. You should have been paying a copay since 2004, but it will not be retroactive!"

Today I called the billing department of the doctor who sent me the bill and was told their records show that I have never paid a copay since 2004 but this time UHC said to bill you as a copay. This billing department told me to "have UHC resubmit it because it seems like an obvious mistake", which I did yesterday.

Either way, when the results of the resubmission of this bill comes back I will call DOA once more to see what they can add to the above list of nonsense answers.

[observer53]

Good luck, I understand your frustration, and confusion.

[dutchman09]

Thanks, I'm sure I'll need it, and then some.

The state of Arizona also contracted with a new Pharmacy Benefits Manager (PBM), MEDIMPACT. Their impacting alright. They took several medications off the Formulary list which caused the copay to go from $40.00 to $80.00 for 3 months.

They also initiated a "Step Care Therapy". It doesn't matter which medication the doctor writes a prescription for, when you go to fill it, it will be refused until MEDIMPACT comes up with the cheapest PC (Plan Cost) for a prescription in that drug family. There has always been 3 classes for a drug in the Formulary: Generic, Preferred Brand, and Non-Preferred Brand. But to sell the cheapest drug first, they moved many drugs from the Preferred class to the Non-Preferred which doubles the copay.

The reason for all this is due to "the fiscal constraints the State is currently facing." What about my 'fiscal constraints'?