Posted on Friday, 29th November 2024 by

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More FEHB and PSHB plans are offering Medicare Prescription Drug Plans (MPDPs) this open season. I reviewed several plan brochures, and you must opt-out if you have Original Medicare and want to remain in your provider’s prescription drug plan. Blue Cross and Blue Shield started offering MPDPs last year.

Once enrolled in an MPDP, you must pay a Part D Income Required Monthly Adjustment Amount (IRMAA) if your income is above a specific limit.

The following is excerpted from the GEHA brochure. They are one of the providers incorporating this next year for those enrolled in Medicare Part A and B. It’s not an option; you will automatically be enrolled in their MPDP unless you request to opt-out.

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GEHA MPDP

According to GEHA, “The Plan will add coverage for a Medicare Prescription Drug plan (PDP) – Employer Group Waiver Plan (EGWP), sponsored by SilverScript, to eligible annuitants and family members enrolled in the High or Standard Option. This Medicare Part D plan is equivalent to, or better than, the GEHA FEHB prescription drug benefits.” They go on to say:

“Eligible members will be automatically enrolled in the GEHA SilverScript PDP effective January 1, 2025. Enrollees will have the ability to opt-out of this coverage by following instructions mailed to them. Declining coverage or “opting out” will allow the enrollee to revert back to their standard FEHB prescription drug benefits. For more specifics regarding this coverage, see Section 9, Medicare Prescription Drug Plan Employer Group Waiver Plan (PDP EGWP).”

Note: GEHA customer service advised me that opt-out instructions must be requested. I asked them to send me a copy on November 19th. To avoid automatic enrollment, you will have 21 days from receiving the letter to contact SilverScript at the toll-free number (833-250-3241) to decline Part D coverage.

What to Expect

If you pay a Part B IRMAA and don’t wish to pay an additional Part D IRMAA, request the opt-out letter from your provider. My wife’s and my prescriptions are reasonable under GEHA’s standard prescription drug plan; we intend to stay with GEHA’s standard plan in 2025 and will opt-out of their MPDP.

There are benefits to MPDP offerings, especially for those not subject to an IRMAA. They include:

  • No deductible
  • Catastrophic Protection Out-of-Pocket Maximum of $2,000 per person annually
  • The plan’s integrated medical and prescription drug overall out-of-pocket maximums apply. Check Section 9 of your provider’s brochure for limits.

Medicare Advantage (MA) Plans

While researching MA plans this year, I discovered several issues with the plans I reviewed. I was comparing GEHA’s standard plan to their new MA plan offering.

One of the benefits of the FEHB plans for those with Original Medicare A & B is that you aren’t limited to the plan’s provider list. You can use any provider or medical facility that accepts Medicare; your plan will cover the deductibles, copayments, and coinsurance.

With Medicare Advantage Part C plans, you must use their provider networks. Most of our doctors weren’t on the list. When I called United Healthcare, the company that manages GEHA’s MA plan, they said to provide a list of the doctors not on the list, and they would confirm if they were part of a Plan Provider Organization (PPO) that would accept payment.

Higher-income retirees will also be subject to Part B and D IRMAAs if they enroll in an MA plan. This is often a tie-breaker for many considering this option.

Another concern is what I mentioned in our Medicare Advantage Plan Primer. “Increasingly frustrated health systems are opting out of contracts with different Medicare Advantage insurers. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers.”

Who Pays What & When

MA plan network providers bill United Healthcare. However, if a PPO doesn’t accept payment, United Healthcare can contact your doctor to explain how the plan works.

If a doctor or hospital refuses to bill UnitedHealthcare directly, they may ask that you pay the full allowable amount. In that case, you can pay the doctor and then submit your claim to UnitedHealthcare. You will be reimbursed for the cost of the claim less your copay.

The following disclaimer is posted on their website: “Out-of-network/non-contracted providers are under no obligation to treat UnitedHealthcare members, except in emergency situations. Please call our customer service number or see your Evidence of Coverage for more information, including the cost-sharing that applies to out-of-network services.”




 

GEHA Plan Comparisons

GEHA publishes a plan comparison chart outlining the benefits of the GEHA Standard and GEHA Standard Medicare Advantage plans. It also provides a side-by-side chart of how their new GEHA Standard EGWP Prescription Drug plan compares to the other two options. A similar comparison chart is available for their High Option.

There isn’t an additional cost to join an MA plan; however, higher-income enrollees may pay a Part D IRMMA that they wouldn’t be responsible for if they remain in the FEHB’s prescription drug plan.

Visit the GEHA site for additional details and explore their plans and the MA option.

Summary

Many plans include an MPDP, and if you don’t review your plan brochure this open season, you may be unaware of this and other new features that may affect you and yours.

Your FEHB / PSHB plan provider networks differ from the Medicare Advantage plans they offer. Confirm the doctors and facilities you currently use are on the MA provider list before signing up. Also, check each plan’s formulary list to confirm the drugs you use are available and at a cost you can afford.

Before signing up for an MA plan, review our Medicare Advantage Plan Primer – What You Need to Know guide. It will help you decide what is right for you.

One of the advantages of the MA and MPDP plans offered by our FEHB/PSHB providers is that you can opt-out at any time and return to your original FEHB/PSHB plan. Several subscribers reported that after requesting to return to their Original Medicare plan, it took many calls and months to effect the change. It wasn’t a smooth transition.

Even if you don’t intend to change plans, it’s advisable to request a print copy of your 2025 plan or go online to review Section 2 (Changes for 2025). You still have until December 9 to review your current plan and explore others of interest.

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Disclaimer: The information provided may not cover all aspect of unique or special circumstances, federal regulations, medical procedures, investment, and benefit information are subject to change. To ensure the accuracy of this information, contact relevant parties for assistance including OPM’s retirement center.

Over time, various dynamic economic factors relied upon as a basis for this article may change. The information contained herein should not be considered investment advice and may not be suitable for your situation. This service is not affiliated with OPM or any federal entity. You should consult with a financial, medical or human resource professional where appropriate. Neither the publisher or author shall be liable for any loss or any other commercial damages, including but not limited to special, incidental, consequential, or other damages.

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