I don’t want to hijack the primary parents caring for the parents thread but I had some more specific questions that may be helpful to all of us navigating these waters.
It appears to me that the pharmacy my parents assisted living center uses is not a "preferred pharmacy" for their Medicare advantage HMO. They are insured with an Independence Blue Cross plan - the largest (by far) insurer in our area. I worked with a state APPRISE counselor and he is the one who alerted me to this. I haven't researched every med they are on to compare prices (because, you know, I have a zillion other things I have to do in my life) yet. I am wondering if anyone has had more experience in dealing with these special pharmacies that supply facilities.
I also get bills from two other places - apparently they order dad’s insulin pen needles from one place, and the alcohol wipes and glucose strips from another. It just seems really inefficient. Is it unusual for Assisted Living places to not use common, preferred pharmacies?
Per their Keystone advantage plan, all bloodwork is supposed to be done at Labcorp as their PCP has captitated to that company. However, dad being a T1 diabetic needs regular fasting bloodwork. He also has a brain injury which makes it very hard to disrupt his normal routine.
Their facility is able to draw blood but insurance won’t pay because they want him to go to Labcorp. It would be FAR BETTER for the patient if he could simply have his blood drawn in his apartment before breakfast. Instead, I need to set up an appointment, go over and sign him out and ensure that NO ONE allows him to eat anything. Then I have to take a T1 diabetic out to the lab and that whole process easily takes two hours from start to finish because he is a slow walker and gets very confused by new situations like this. Only to bring him back to his facility and breakfast is over and he is now really screwed up on his meal patterns and insulin for the day.
Is there any hope of getting the insurance company to grant an exception in cases like this? I thought about just paying out of pocket until I saw it costs about $800!
As my husband says, “it’s never easy”. When my aunt was in an extended care facility, we used her mail order pharmacy plan and had the medication delivered to the pharmacist at the facility. Is this an option for you? I kept track of and did the ordering of meds.
Does the insurance plan cover a VNA service that could go to the your dad at his facility when lab work is needed and draw the labs and deliver them to labcorp? His MD could electronically send the order to labcorp and the nurse or lab tech can drop off the specimen.
After jumping through hoops to take care of my mom and my aunt, I’ve become an expert at closing loop holes and “making things work”. It is exhausting, aggrevating and time consuming. Sending hugs!
I also began ordering my aunt’s meds from her insurer’s mail order pharmacy because it was a lot cheaper. than the pharmacy her ALC used I think the suggestion of having a visiting nurse draw blood and send it to Labcorp is an excellent one as well, if possible.
@surfcity- not an expert and there may be regional differences in plans offered. Sharing a little info in case helps: When my parents were in AL, the AL used only two pharmacies. The criteria included that the pharmacies be willing to dispense pill scripts in flat blister packs that worked with their med cart system, be willing to deliver in emergencies, etc.
HMO plans that intersect with Medicare sometimes forfeit the choice of providers that other Medi-gap policies and Medicare itself offers. Drug prices, monthly premiums and formularies changed frequently over the 15 years I kept up with this for my folks: I did not deem it practical to change plans to accommodate those fluctuations.
If your parents plan to stay where they are, perhaps eventually including nursing home care at the same facility, an $800 a month med charge to start seems worth minimizing and it might be worthwhile to confer with someone with expertise about other available Medi-gap policies during an open enrollment season. My parents’ script plan was separate from their Medi-gap policy. It can seem a moving target. Many states have experts on phone lines to help de-code what would work best in specific situations. It was very helpful to me to call; it seems a bit of luck is involved in reaching a the right person. Also, finance offices at facilities may have some perspective on which plans are workable for billing. All the best with this.
I can’t speak to blood draws, but a visiting nurse or similar would be a great idea if you can find one.
For the pharmacy, I also went through “stages”, when she first moved in, I had someone pick up from her local pharmacy. (the same extra care giver not AL person because Mom was still in “independent” living). Then we moved her to the assisted living side and the AL place wanted to use a non-preferred pharmacy for getting the bubble pack doses, but after some months they did get a pharmacy which was preferred. THEN their pharmacy was going to be dropped from Cigna (Mom’s medicare supplement RX provider). I called Cigna and whined and pleaded and also called the pharmacy and was shocked and horrified and eventually their pharmacy got requalified or whatever you call it. So in your spare time :(( call the pharmacy you want to use, call the insurer and see if they will qualify the pharmacy the AL place wants to use.
And the final thing was that when hospice was involved, their pharmacy (Mom still got thyroid meds but was off others except the occasional Tylenol until the end case morphine) billed medicare directly and the supplemental insurance didn’t matter anymore.
It is a stages / process thing
Wow - thanks for all the advice. Because of @ECmotherx2 's comment I realized that the expensive part of the bloodwork is the lab portion. The insurance would absolutely not cover VNA for just a blood draw but I can have the onsite nurse do the draw with the Labcorp vials and drop the specimens at my local Labcorp! (https://www.labcorp.com/provider-services/other-services/home-healthcare)
[The $800 was not a medication cost, it was the lab cost to have blood work done outside the capitated agency. Sorry for being confusing]
So I plan to call the facility tomorrow to arrange this. Dad is currently having a visiting Bayada nurse because he was in the hospital last week and that is standard after returning home.
As far as the Rx plan, there is definitely value in having the assisted living place ordering all the meds and supplies. I have so much other work to do for them (referrals, labs, doc paperwork, driving, laundry, etc) that I want to be able to off-load that on to them. It seems like it’s not a huge amount of money - $3-5 per Rx here and there but it adds up. Plus to me it’s more the principle of the thing - all these seniors most likely have an IBX plan and the pharmacy is not preferred.
I can’t tell you what a relief it is to have (I think) a solution to this fasting blood work. I am really being stretched too thin with all the work my folks require and so it’s great to eliminate one more thing. Thank you!
Well rats. The director of nursing just told me that the ALC cannot do the blood draw for Labcorp. I have to take him myself, which means taking off a half day of work and risk dad going very low on sugar. Clearly not the best thing for the patient but I guess the insurance company sees that as a secondary priority to saving money.
For a moment I seriously thought - how hard can it be to stick a needle and vial in dad’s arm?? :))
Darn; that would help you and your father so much. May be time to take a fresh look at the insurance policy Medi-gap/ and or prescription Part D options. There is open enrollment once a year, plus certain circumstances changing may allow for an out of enrollment season change. IME, you want all the help you can get on-site. HMOs can be more restrictive about providers than some other type of plans that have fewer in-network constraints, PPOs, for example.
AL may be aware of resources to help you look at all insurance options in an effort to maximize access. Do you know exactly what the AL would need in place to be able to do the blood draw and order meds? What Medi-gap insurance seems to work best for residents? Also, in the meantime, what happens if your father needs an urgent blood draw? Is an ambulance called to take him to the ER? This helps with your cost benefit analysis of various plans. As meds can also change abruptly, you may want to be prepared with better coverage.
All the best with it. The good news is when the plan is right, it can be seamless and smooth.
@surfcity, hang in there. None of the entities seem to care about the patient, how terribly frustrating. Was finally able to get incontinence supplies covered for mom when she went on medicaid last year, it helped out so much since I was paying for them and no longer had to do the ordering, etc. The company would call me once a month to very the existing order and would deliver. Mom went on hospice and they were notified of this through insurance. Now they cancelled the orders as their policy states if a patient is on hospice, they must bill medicare first, (who does not cover these supplies) and cannot process through medicaid, (as they have been doing for a year), until they hear from hospice and set up a “special account”. I felt horrible to have to bother the hospice social worker to contact the supply company and waste her time over a ridiculous policy. It is NEVER easy.
My dad was on Medicare and a supplement. That covered all the meds that the chosen pharmacy used. When people look for a facility, finding out what pharmacy and home health group they use does not seem a priority.
Similarly, while internists, psychologists, dermatologists, podiatrists make regular visits to ALFs and SNFS, these professionals may not be on HMO plans.
@surfcity Does your dad have two separate insurance plans (Medicare and Blue Cross)? We’ve encountered something similar with my mother, who is also diabetic. It took a bit of work and several phone calls, but what we did was to have Medicare billed first and then have the claim(s) submitted to BCBS. That way the BCBS plan will usually pay the 20% Medicare doesn’t pay as well as 80% if Medicare doesn’t pay at all.
I swear that labs need to work with doctors to have similar coverages. My own pap smear (performed at a clinic I’ve been going to for 25 years) was sent to a lab this year that apparently is out of network. It’s so frustrating.
@tutumom2001 yes, they both have medicare and a “Medicare Advantage” plan. I met with an APPRISE counselor about a month ago (this is the PA certified program that provide free counselors to help seniors pick health insurance). From what I recall, he said something that when you first sign up for Medicare, you have to choose which plan comes “first.”?? I asked because my mom had been Rx a expensive drug ($1400/month for our portion) and her doctor said for her patients that are “medicare first” the med is usually paid for. But mom’s Medicare Advantage plan has to come first so the cost didn’t get any lower than $1400. (We opted not to use it).
Having said all that, I am not confident in my knowledge of the system. The APPRISE counselor was a retired chemical engineer who spent three months in training to volunteer to help people. It was crazy the amount of research and paperwork we had to go thru to figure out the best plan - putting in all their meds, changing pharmacies to see if rates got any better etc.
Part of the issue is the medications are Tier 3 or 4 and are not" preferred" by his plan. He always ends up in the “donut hole” whatever that means. Well, I know what it means, but it is still confusing to me.
Yes @bookworm it did not even occur to me to look at the pharmacy and home health plan the ALF used when we were researching. And I am pretty “belt and suspenders” in double checking everything. Well, actually I had planned to order and deliver all the meds myself, but then once I realized the MD was tweaking prescriptions a couple of times a month, it got to be way too tedious, plus mom had to keep them locked up in her room etc. Not worth the trouble.
I found they don’t want families providing the meDs. I argued that my dad needed something -antibiotic?- and couldn’t wait for the pharmacy delivery. That was the only time I could do that
@surfcity , Is there any way your dad could switch from his Medicare Advantage plan back to original Medicare plus a supplemental Medigap plan and a Part D prescription plan? It would be more expensive but he would have a lot more freedom as far as choice of doctors, pharmacies, etc. He could make the switch now during the open enrollment period but he would be subject to medical underwriting and might be denied, depending on his health. That’s the big downside.
My mother has original Medicare plus a Medigap policy and lives in an independent living facility. Whenever she needs to have blood drawn, her doctor contracts with a service that sends a nurse to her apartment to do the draw. She has even had them come to her apartment to do x-rays and an echocardiogram. She doesn’t walk well and it’s hard for her to spend long hours at the outpatient facility for tests, so this has been a lifesaver.
Might as well try to ask for coverage as an exception due to special circumstances.
But yes, changing to another health insurance may be necessary. My father had an HMO which started costing him a lot out of pocket, so with some help I ended up switching him to Medicare primary and for the rest. Nothing out of pocket past the Medigap premium, which I think was around $150 per month.
The assisted living facilities used Labcorp at will, but I believe it was through the local hospital.