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Why You Should Compare Medicare Plans at Your Pharmacy

Posted on in Industry Updates by Amplicare Team

Choosing a Medicare plan after comparing a long list of options may be daunting for many patients. But as their pharmacist and a key resource, you can help ease them through the process. Considering that about 90% of Medicare beneficiaries are not enrolled in the most cost-effective plans for their medications, conducting plan comparisons is essential to ensuring patients with a limited understanding of Medicare are choosing a plan that makes the most sense for them.

Statistics show that Medicare patients are generally less informed about their plan options than they let on. According to a 2019 HealthMine survey of 800 Medicare Advantage beneficiaries, only about 32% of those surveyed knew about the CMS Star Rating system. Of those, only 49% considered the ratings when enrolling in a health plan. A study published in the Journal of Patient Experience also found that members who believed the Medicare Part D selection process was complicated were less likely to consider switching plans. Study participants noted an overwhelming process with too many options and difficulty changing plans as factors that prevented them from switching. They also sought help from a “live” person such as an insurance broker to address their confusion with the system.

Being a community pharmacist means you are well-placed to play the important role of helping patients navigate the complexities of Medicare. In 2019, a 15 percent increase in Medicare Part D plans from 2018 meant more choices for beneficiaries. CMS also introduced changes to Medicare Part D and Medicare Advantage plans that included more flexibility around benefits and stabler and lower prices in some instances. This increase in options creates an even greater need to encourage your patients to reevaluate their plans this upcoming Medicare Open Enrollment.

Additionally, many patients tend to stay on their plans despite changes in formularies, networks, premiums, and drug prices out of a reluctance to switch plans. There is also a common misconception that choosing a health plan is a one-time decision, as some patients believe that a plan that has worked for them in the past will continue to do so. In reality, changes in coverage, formularies, and more could mean that their plan is no longer the most cost-effective option and switching to a new one could save them money.

Offering plan comparisons is a good opportunity for you to improve patient retention, build meaningful relationships, and drive growth for your pharmacy during Open Enrollment. But opportunities also exist to support your patients year-round. In 2017, the proportion of people in the U.S. aged 65-plus was projected to increase from 14% to 21% over the next 20 years, meaning that a greater number of people will become eligible for Medicare. These newly eligible patients present a great opportunity for your pharmacy to be proactive about helping them understand Medicare.

Dual-eligible patients are another large patient population that is eligible to switch Medicare plans quarterly throughout the year. You might think these patients would be less receptive to switching, since their copays and premiums are already so low, but they may actually be the ones to benefit the most from a simple plan comparison. For one, dual-eligible patients are good candidates for non-preferred plans since there is no copay incentive for them to go to a particular pharmacy (i.e., their copays remain the same regardless of whether or not their pharmacy is preferred). This benefits the pharmacy as you get reimbursed more and pay less in DIR fees on non-preferred plans. Additionally, Medicare-Medicaid patients often pay a $0 premium for their Medicare plan due to the set ‘benchmark’ cost in each state. Each state sets a certain amount up to which they will fully cover the cost of a patient’s Medicare premium. If a plan’s premium is lower than this ‘benchmark’ amount, the dual-eligible patient pays a $0 premium if they choose to enroll in the plan. Dual-eligible patients are often auto-enrolled into a benchmark plan, but this plan does not necessarily cover all their drugs or provide fair reimbursement to the pharmacy. With 215 benchmark plans across the 50 states, it is imperative to guide your dual-eligible patients to find the best plan for themselves. 

There are other special circumstances under which patients can switch plans outside of Open Enrollment. This includes patients who:

  • Move to a new service area or within the same service area, but are not provided more plan option at their new address
  • Move back to the U.S. after residing outside of the country
  • Just moved in, out, or currently reside in a skilled nursing or long-term care facility
  • Were recently released from jail
  • Are no longer enrolled in Medicaid
  • Lose coverage from their employer or union
  • Are enrolled in a PACE plan
  • Are enrolled in a plan which Medicare has officially sanctioned
  • Qualify for extra help
  • Are enrolled in SPAP
  • Are interested in enrolling in an SNP
  • Are currently in an SNP and no longer have the special needs condition

As you help your patients consider their Medicare plan options this Open Enrollment and beyond, keep in mind that Amplicare provides the tools to make plan comparisons easy. This includes a formulary lookup tool that compares medications across plan formularies, a doctor lookup tool to help with Medicare Advantage comparisons, reports on newly eligible and dual-eligible patients, and a report to help you during the Medicare Open Enrollment period. By encouraging your patients to look at their Medicare plan options, you are helping them make an important decision that will affect both their health and wallet.

To learn more about how Amplicare can help you compare plans and detect win-win opportunities for your patients and your pharmacy, reach out to us to schedule a demo

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