Life After 50 Expo

Dear Marci,

I recently started taking a new medication. It’s covered by my Part D plan, but when I went to the pharmacy, I was charged a high copay! What’s going on? How do I fix this?

-Maria (Sacramento, CA)

Dear Maria,

If your Part D plan covers your medication but your copayment is expensive, it could be that the medication is on a high tier. Part D plans use tiers to categorize prescription drugs. Higher tiers are more expensive and have higher cost-sharing amounts. Each plan sets its own tiers, and plans may change their tiers from year to year.

If you can’t afford your copay, you can ask for a tiering exception by using the Part D appeal process. A tiering exception is a way to request lower cost-sharing. To request a tiering exception, you or your doctor must show that the drugs for treatment of your condition that are on lower tiers of your plan’s formulary are ineffective or dangerous for you. Here is some guidance on requesting a tiering exception:

If you are charged a high copay at the pharmacy, talk to your pharmacist and your plan to find out why. If your copay is high because your prescription is on a higher tier than other drugs to treat your condition on the formulary, you can ask for a tiering exception.
Note that you can’t request a tiering exception if the drug you need is in a specialty tier. The specialty tier is limited to drugs above a certain dollar amount and plans may not require more than 33% coinsurance for drugs on this tier.
Ask your plan how to send your tiering exception request. It’s usually helpful to include a letter of support from your prescribing health care provider. This letter should explain why similar drugs on the plan’s formulary at lower tiers are ineffective or harmful for you.
If your plan approves your tiering exception request, your drug will be covered at cost-sharing that applies to the lower tier. Normally, an approved exception will be in effect until the end of the current calendar year. If your plan denies your request, it should send you a letter titled Notice of Denial of Medicare Prescription Drug Coverage. You can appeal this decision.
You may wish to consider switching plans during the Fall Open Enrollment Period to a Part D plan that covers your drug with lower cost-sharing. I hope this helps. Best of luck!

-Marci

Health Tip
November is National Chronic Obstructive Pulmonary Disease (COPD) awareness month. COPD is a chronic disease that makes it more difficult to breathe. According to the American Lung Association, early detection and treatment is very important. They suggest that if you are experiencing any of the following symptoms, you should discuss COPD with your doctor:

Chronic cough
Shortness of breath while doing everyday activities
Frequent respiratory infections
Blueness of the lips or fingernail beds
Fatigue
Producing a lot of mucus
Wheezing

Dear Marci,

I went to the doctor last month and now owe more than I thought I would. I called the office and learned that they charged me a facility fee. What is this?

-Roman (Baton Rouge, LA)

Dear Roman,

You may owe a facility fee when you go to a hospital-owned outpatient clinic. In other words, when you see a doctor at a facility that is owned by a hospital, rather than owned by the doctor. These facility fees help the hospital maintain the clinic by offsetting operational costs.

If your doctor’s office charges you a facility fee, it will be in addition to the cost of your medical care. Your doctor’s office may call it something like a “room charge.” Facility fees can range a lot in cost; the fee could be $15 or $150.

Under Original Medicare, facility fees are a covered service, and you are responsible for 20% of the cost of the fee. Medicare Advantage Plans must also cover facility fees, but there is no requirement as to how much of the fees the plan must cover. Because of this, your copays could be high. If your Medicare Advantage Plan denies coverage for the facility fee, you should appeal on the basis that Medicare Advantage Plans must cover the same services covered by Original Medicare.

Hospital-owned outpatient practices must notify you that you could potentially be charged for use of the facilities. If they don’t, you should file a grievance with your plan and a complaint with Medicare. You may also consider switching to a different provider in the future to avoid these costs.

I hope this helps!

-Marci

Dear Marci,

I recently enrolled in Original Medicare. I know that with Original Medicare, I can see most any provider. Will my costs be the same regardless of which provider I see? Or is there anything else I should consider to get the best costs for my care?

-Iris (Huntington, NY)

Dear Iris,

If you have Original Medicare, your Part B costs once you have met your deductible can vary depending on the type of provider you see. For cost purposes, there are three types of providers, meaning three different relationships a provider can have with Medicare. A provider’s type determines how much you will pay for Part B-covered services.

Participating providers accept Medicare and always take assignment. Taking assignment means that the provider accepts Medicare’s approved amount for health care services as full payment. These providers are required to submit a bill (also called filing a claim) to Medicare for care you receive. Medicare will process the bill and pay your provider directly for your care. If your provider does not file a claim for your care, there are troubleshooting steps to help resolve the problem. If you see a participating provider, you are responsible for paying a 20% coinsurance for Medicare-covered services. Certain providers, such as clinical social workers and physician assistants, must always take assignment if they accept Medicare.

Non-participating providers accept Medicare but do not agree to take assignment in all cases (they may on a case-by-case basis). This means that while non-participating providers have signed up to accept Medicare insurance, they do not accept Medicare’s approved amount for health care services as full payment. Non-participating providers can charge up to 15% more than Medicare’s approved amount for the cost of services you receive (known as the limiting charge). This means you are responsible for up to 35% (20% coinsurance + 15% limiting charge) of Medicare’s approved amount for covered services. Some states may restrict the limiting charge when you see non-participating providers. For example, New York State’s limiting charge is set at 5%, instead of 15%, for most services. For more information, contact your State Health Insurance Assistance Program (SHIP).

Opt-out providers do not accept Medicare at all and have signed an agreement to be excluded from the Medicare program. This means they can charge whatever they want for services but must follow certain rules to do so. Medicare will not pay for care you receive from an opt-out provider (except in emergencies). You are responsible for the entire cost of your care. The provider must give you a private contract describing their charges and confirming that you understand you are responsible for the full cost of your care and that Medicare will not reimburse you. Opt-out providers do not bill Medicare for services you receive. Many psychiatrists opt out of Medicare.

Be sure to ask your provider if they are participating, non-participating, or opt-out. You can also check by using Medicare’s Physician Compare tool.

-Marci