I (Amy) am pleased to introduce our guest blogger, Judy Sulick. Judy is a pharmacist and has been working in health care for nearly 30 years. With almost two decades of executive corporate positions, extensive travel and career focus, she has shifted her attention to a local health benefits management position. She resides in Dublin, Ohio where she balances a fulfilling position with her talent for art, gallery displays, commission painting and passion for all things creative. I have personally known Judy for nearly 20 years and I just adore her. She is like the sister to me that I never had. Judy jumped at the chance to be a guest blogger which doesn’t surprise me given her giving, creative personality. It is my pleasure and with great honor to introduce our audience to Judy and her take on navigating health care.
As a health care professional, I notice that friends, family and colleagues discuss personal health matters with me and even solicit guidance in navigating health care resources. It can be an illness, an injury, a procedure or preventive health care appointment. I also notice that aging family members are more likely to look to us for support, often for health related matters. As family members are aging, try to be proactive in anticipating their needs and understanding what choices are possible with health insurance plans.
As a health care professional, I notice that friends, family and colleagues discuss personal health matters with me and even solicit guidance in navigating health care resources. It can be an illness, an injury, a procedure or preventive health care appointment. I also notice that aging family members are more likely to look to us for support, often for health related matters. As family members are aging, try to be proactive in anticipating their needs and understanding what choices are possible with health insurance plans.
The complexities of commercial health plans and Medicare plans can be overwhelming. In the future, health care exchanges could become options through the Affordable Care Act. At some point, we may be called to make decisions or assist in deciding which plan offers the level of access, cost and quality of services for our or a loved ones’ needs.
Here are some things to consider and a few resources that might help:
• Medicare:
o Medicare is a federal health insurance program for U.S. citizens (or permanent legal residents for 5 continuous years) who:
• Are 65 years of age or older;
• Are under 65 and disabled and receiving benefits;
• Have end-stage renal disease; or
• Are eligible for Social Security Disability Insurance and have ALS (Lou Gehrig’s disease)
o When a person turns 65, it’s important to assure that they’ve enrolled in Medicare. Medicare Part A addresses inpatient insurance. Medicare Part B addresses medical outpatient insurance. In a nutshell, Medicare pays primary and another commercial plan can pay secondary for medical claims.
• Medical: In addition to Medicare, medical plans are offered through various commercial insurers. Some people have access to medical insurance through their retirement plan. Others are able to enroll in individual or group plans. In choosing among various plan options:
o Consider the current status of health and whether you anticipate frequent visits to the doctor. There are options where if you anticipate good health and infrequent need to see the physician, you may be willing to risk a higher out of pocket limit in exchange for lower monthly premiums throughout the year.
o Some medical insurers have a specific network of physicians that are considered ‘in network’. If your physician or local hospital is not in this network, there will likely be a different member cost share for the service. Consider travel and ‘snowbirds’ with extended temporary residence. Are there providers within network in those areas?
o Home Health Care: With the trend toward hospitals decreasing the length of inpatient stay, long term care or home health care is often needed to continue recuperation or rehabilitation. Look at the scope and duration of services available within the benefit. What qualifies the member for Home Health Care after a hospitalization or for hospice?
o How much can you spend? There can be a deductible where the member is required to pay up to that amount before the plan requires only the established copayment/coinsurance. Also, evaluate the maximum out of pocket payments required until the plan covers more of the expenses. Think about the member’s overall monthly budget, including pharmacy costs.
• Pharmacy: These benefits are often bundled with the medical plan enrollment. If the member is enrolled in Medicare and a plan that offers prescription benefits, it is likely a Medicare Part D plan.
o Medicare Part D was established by Title I of the Medicare Prescription Drug, Improvement, and Modernization Act. The goal is to provide prescription benefits to Medicare beneficiaries whereby anyone with Parts A or B is eligible. Typically, plan sponsors or insurers leverage government subsidies in Part D plans to offset the cost of premiums for members.
o Typically pharmacy benefits offer both a mail service and a retail pharmacy benefit. Some retail pharmacy benefits have a specific network of pharmacies and different member cost share for out of network pharmacies. Mail service pharmacy is reasonable for prescriptions where the medication dose is stabilized and chronic in nature (i.e. Blood pressure medications). Retail pharmacy is reasonable for prescriptions that might not yet have consistent dosing or short-term in nature (i.e. Antibiotics). Overall, plan sponsors use mail service pharmacies to leverage better pricing, thereby offsetting the cost of premiums to members.
o As with medical plans, consider the deductible, copayment/coinsurance and maximum out of pocket expenses required by the member until the plan covers more of the cost.
• Dental and Vision: These benefits are typically offered with premiums separate from the Medical/Pharmacy bundle.
o Consider the need for glasses, contacts. Also consider the potential for needs such as glaucoma screenings or ophthalmologic care secondary to diabetes. Evaluate the insurance plan contribution toward services and frequency with which the services are allowed.
o Evaluate the coverage around dental procedures, dentures, reconstructive or preventive care.
• Long Term Care Insurance: When available, premiums are often more affordable the younger the enrollee. Look at the potential dollar benefit paid to the member per month as well as the necessary qualifications to enact the benefit.
Many resources are available to help you understand how to navigate health care options. Some are through commercial insurers, while many are through government program websites. Here are a few:
Essentially, medical and pharmacy benefits drive access to and choices about our health care. Our benefits drive our comfort and confidence in having the resources at hand to address the issues.
Be proactive. Be informed.
Judy Sulick, R.Ph., M.S.
Assistant Director, Pharmacy Benefits and Health Care Enrollment
State Teachers Retirement System of Ohio
sulickj@strsoh.org
