Plan Finder Part D Formularies Not Accurate

[Spud]

Hi, I got a call from a customer that switched pdp's during aep. They indicated the information (drug cost/drug copay/drug tier) on the Plan Finder was not the same when they went to enroll in the plan's mail order service. The Plan finder information was for 'mail order'. Naturally the customer was upset with the prospect of having to pay more than what they were told. We initiated a 'complaint' with Medicare.

I was working with a new t65 today for a pdp...same situation; plan finder's med cost/tier info was not the same when I checked it with the rep from the plan.

Anyone else running into this? Any other solution than filing a 'complaint' (besides not enrolling people in pdp's)?

 

[yogooglethis]

Hi, I got a call from a customer that switched pdp's during aep. They indicated the information (drug cost/drug copay/drug tier) on the Plan Finder was not the same when they went to enroll in the plan's mail order service. The Plan finder information was for 'mail order'. Naturally the customer was upset with the prospect of having to pay more than what they were told. We initiated a 'complaint' with Medicare.

I was working with a new t65 today for a pdp...same situation; plan finder's med cost/tier info was not the same when I checked it with the rep from the plan.

Anyone else running into this? Any other solution than filing a 'complaint' (besides not enrolling people in pdp's)?

There has always been discrepancies between the carriers formulary and www.medicare.gov so I use the Medicare website to find what appears to be the most cost effective plan and then I go to the carriers website and check my math.

If dealing with any high cost brand name drug this is a must because a screw up with that will set off the alarms and as you know it's always the agent fault even if Medicare and the carrier publish erroneous information.

 

[Spud]

Hi, thanks for sharing the comment; the issue with that approach is the yes/no if 'all of the drugs are in the formulary'. If the plan finder indicates 'no', but they actually are, you have eliminated that vendor's plan.
Have you filed a complaint with medicare when you found this situation? If yes, how did that come out?

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After thought; this can easily be interpreted as 'vendor fraud' imho from the point of view that the vendor is not offering accurate/complete information (and checking it); how many people use plan finder (without an agent involved) to make their own decisions about pdp enrollment; medicare pushes the use of this tool...so does ship/shiba.
Has anyone found the plan finder tool regarding ma/mapd plans inaccurate when compared to the actual vendors data?

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Hi, I did a bit more digging into the cms web site and found the vendors handbook for submitting this information. After reading appropriate sections of this, I am anticipating the 'complaint' avenue should provide the corrective action. If this turns out not to be the case, I will share what actually happens here.

 

[BeeSelective]

Doesn't it state that it is an "estimate"?

 

[yogooglethis]

Hi, thanks for sharing the comment; the issue with that approach is the yes/no if 'all of the drugs are in the formulary'. If the plan finder indicates 'no', but they actually are, you have eliminated that vendor's plan.
Have you filed a complaint with medicare when you found this situation? If yes, how did that come out?

----------

After thought; this can easily be interpreted as 'vendor fraud' imho from the point of view that the vendor is not offering accurate/complete information (and checking it); how many people use plan finder (without an agent involved) to make their own decisions about pdp enrollment; medicare pushes the use of this tool...so does ship/shiba.
Has anyone found the plan finder tool regarding ma/mapd plans inaccurate when compared to the actual vendors data?

----------

Hi, I did a bit more digging into the cms web site and found the vendors handbook for submitting this information. After reading appropriate sections of this, I am anticipating the 'complaint' avenue should provide the corrective action. If this turns out not to be the case, I will share what actually happens here.

I am afraid you may have opened up a complaint against yourself if you advised a consumer solely based on the data in wwww.medicare.gov formulary finder because before you can get in to drug search function you have to agree to the ''terms of use agreement '' including the limitations.

'' Your use of and browsing in the CMS Websites are at your risk. CMS does not warrant that the service will be uninterrupted or error free. CMS is not liable for any incidental, consequential, direct, indirect, or punitive damages arising out of your access to, or use of, the CMS Websites.''

https://www.medicare.gov/find-a-plan/staticpages/UserAgreement.aspx

That's why I always check the carriers website first before making a final recommendation.I have been using the Medicare Formulary Finder since it was first created and one thing I learned early on is that there are input errors with the data but biggest issue you have to be aware of is that it is not always updated in a timely manner when the carriers make changes.

 

[cadylou]

I take a person's drug list & once I've run the Medicare.gov estimate, I go into each provider's formulary to check for sure. I don't carry all companies - but carry printed formularies for the plans that I do have, and do online searches at the provider's website if it's a plan I don't carry. Unfortunately this is complicated and time consuming, but I continue to assist with this function because my clients are most worried about expenditures in this area. If they purchase other insurance from me (Med supps, etc.) I provide the service. Even if you file a "complaint" - I doubt you'll win - as someone here said - the Medicare.gov site plainly states it's an "estimate" and you should always do further due - diligence - especially if you're an insurance professional.

 

[yogooglethis]

I take a person's drug list & once I've run the Medicare.gov estimate, I go into each provider's formulary to check for sure. I don't carry all companies - but carry printed formularies for the plans that I do have, and do online searches at the provider's website if it's a plan I don't carry. Unfortunately this is complicated and time consuming, but I continue to assist with this function because my clients are most worried about expenditures in this area. If they purchase other insurance from me (Med supps, etc.) I provide the service. Even if you file a "complaint" - I doubt you'll win - as someone here said - the Medicare.gov site plainly states it's an "estimate" and you should always do further due - diligence - especially if you're an insurance professional.

I agree .I believe that the dirtiest,hardest and most dangerous aspect of being a well rounded professional and go to expert in all types of Medicare Health plans is being able to explain and find the most or one of the most cost effective plans. If there is a significant difference in cost between the plans you offer and the most cost effective plans I think it's also good to either give the case to someone you know who is appointed with the carrier or have the consumer call the carrier with the most cost effective plan directly and have the carrier's telesales agent check the drug list for an extra layer of certainty .I think telling them to enroll online or doing it for them if your not appointed with the carrier is a little risky if things go awry.

 

[Spud]

I wonder why Medicare opened up a complaint then...they understood the issue.


A bigger issue (to me) is how Medicare promotes the use of the tool during AEP, then less than 1-month into the new year, the vendors still have not confirmed the accuracy/completeness of their data. I understand the need to add/drop med's during the year because of market place changes.


Without CMS holding the insurance company accountable for their own actions (verifying data submitted) , it becomes very easy for insurance companies offering pdp's to report their 'intentions' for a certain formulary to CMS pre-AEP for the following year, then implement a different formulary on January 1...a formulary that, after they lock in the new people, they say 'just kidding', we really have your med's in a different tier at a different cost. They make more money, the consumer loses. I am expecting CMS to hold the insurance company accountable in this specific situation.

I am afraid you may have opened up a complaint against yourself if you advised a consumer solely based on the data in wwww.medicare.gov formulary finder because before you can get in to drug search function you have to agree to the ''terms of use agreement '' including the limitations.

'' Your use of and browsing in the CMS Websites are at your risk. CMS does not warrant that the service will be uninterrupted or error free. CMS is not liable for any incidental, consequential, direct, indirect, or punitive damages arising out of your access to, or use of, the CMS Websites.''

https://www.medicare.gov/find-a-plan/staticpages/UserAgreement.aspx

That's why I always check the carriers website first before making a final recommendation.I have been using the Medicare Formulary Finder since it was first created and one thing I learned early on is that there are input errors with the data but biggest issue you have to be aware of is that it is not always updated in a timely manner when the carriers make changes.

 

[cadylou]

One other thing - I have a relationship here with a Medicare Advocate who is certified through CMS. He is not a salesperson, so sometimes when I have a person with a complicated drug situation, I refer them to him. Then, I've helped get them to an "expert" and I'm off the hook. It's been very helpful, and my client likes the fact that I have resources who can help with products that I may not carry directly. Just food for thought. . . . .

 

[yogooglethis]

I wonder why Medicare opened up a complaint then...they understood the issue.


A bigger issue (to me) is how Medicare promotes the use of the tool during AEP, then less than 1-month into the new year, the vendors still have not confirmed the accuracy/completeness of their data. I understand the need to add/drop med's during the year because of market place changes.


Without CMS holding the insurance company accountable for their own actions (verifying data submitted) , it becomes very easy for insurance companies offering pdp's to report their 'intentions' for a certain formulary to CMS pre-AEP for the following year, then implement a different formulary on January 1...a formulary that, after they lock in the new people, they say 'just kidding', we really have your med's in a different tier at a different cost. They make more money, the consumer loses. I am expecting CMS to hold the insurance company accountable in this specific situation.

Once the complaint makes it's way to the carrier I believe in this case it will be sent to the compliance dept of the carrier because the blame can not be placed on the Medicare website -it did nothing wrong according to the terms of use agreement.

It is not clear to me from your post if you are the AOR here or if you just advised on what plan to enroll in but if you are the AOR you may be getting a compliant because most carrier's would not take the fall for this especially with the star ratings being so important now.

If you do get a complaint you are not allowed to contact the consumer after that point so if you are still friendly with the client I would talk with them now to let them know as a result of the complaint they filed with Medicare that you may blamed by the carrier for this honest mistake so as to minimize the damage if the carrier contacts your client