Episode 93 – Making the most of your retiree health coverage

Medicare doesn’t cover every health care expense, but the PEBB retiree insurance can help fill some of the gaps. Additional benefits can include chiropractic care, massage therapy, physical therapy, vision, hearing and naturopathic care. Tune in to find out how to make the most of your coverage.

Episode transcript:

[music intro]

Jenny

Welcome back to Fund Your Future with DRS. Today we’re excited to welcome back Laura from the Washington State Health Care Authority and she’s here to talk about the extra benefits that are available to retirees through the PEBB Insurance Coverage program. Welcome, Laura.

Laura

Thanks so much for having me back.

Jenny

Yeah. So, when we say extra benefits, what types of services are we talking about?

Laura

Yes. So today I’m going to talk about the extra benefits that are available to PEBB retirees who are on Medicare. So typically, when we think of extra benefits, we’re talking about services that exceed what Medicare covers. So, the big examples would be acupuncture, chiropractic care, massage and physical therapy, vision, hearing and naturopath. These either have no or very limited coverage with Medicare. So, these are in addition to what Medicare covers. And these are great benefits that are included in the retiree plans.

Jenny

Okay great. So not covered traditionally by Medicare but are generally covered by PEBB coverage. Correct. Perfect.

Seth

Are they generally covered by all the different? I know there are multiple options within PEBB. Are they generally covered by all the different PEBB varieties?

Laura

Yes, with one caveat. So, I’ll talk a little bit about the Medicare supplement Plans F and G. So, these operate separately than our other plans do simply because they’re a Medicare supplement plan. Medicare supplement plans are designed to only supplement the services that Medicare covers. So, Medicare has some very limited coverage for acupuncture, chiropractic and physical therapy.

So, if a person in Plan F or Plan G accesses one of those types of services, and it falls within the limited type that Medicare covers, then they would have coverage. But they’re not going to have the robust coverage. That is in addition to Medicare services, kind of like what we talked about before. All of our other plans do have an aspect of that other services, however.

Jenny

And then can you talk a little bit about exactly how these types of services are paid for by the retiree, and maybe how frequently a person could use these particular services?

Laura

Sure. So, depending on the plan that someone’s enrolled in, there might be a fixed dollar amount that you pay per visit, or you may pay a percentage of a copay. So, most of the plans also have a limit on how many services are covered per year. So again, this can vary per plan depending on what you have.

The service limits, I would say a general range would be 24 to 30 visits per plan year, depending on which service you’re utilizing. And when I talk about that, I’m specifically talking about the acupuncture, chiropractic massage and physical therapy and naturopath. We’ll talk a little bit separately about vision and hearing because they work a little bit differently. And obviously they don’t really have cause to have limits on how many times you can use those benefits per year as far as seeing a provider.

Jenny

Okay. Even still, it’s like 24 times a year. That’s almost twice a month. So, it’s really great for those particular benefits like massage and physical therapy.

Laura

Yeah, absolutely.

Seth

And then not all of those types of service providers I think even accept Medicare. And how would a person know? So, there’s a massage therapist down the road and I’m living in this area. How would I know if that person participates in PEBB coverage? How would I look that up? Or what sort of due diligence should a person do?

Laura

Yeah. So, it again would depend on which plan you have. So, some plans will still require that you see an in-network provider. And with these extra services, it wouldn’t hinge on the typical rule of seeing a provider who accepts Medicare, because some of these obviously are not Medicare covered services. But you might still need to see an in-network provider in order to get the best rate for your plan.

Some of the plans also have options where you can see any provider, but you would have to pay upfront for the service, and then you submit a claim to your insurance carrier for reimbursement. So, it really depends on how your plan operates with those benefits. So, we always would recommend that you check with the plan before you utilize the benefit.

Preferably. And you just can call the number on the back of your insurance card and they’ll be able to guide you through the process. And it is really helpful if you can do that ahead of time. So, you know exactly what to expect and so that you understand the process. If you end up submitting claims on your own, it’s really nice to kind of get a handle on that process. Make sure that your provider gives you all the information you need in order to submit that claim.

Jenny

So, with Seth’s example of the massage provider down the street, even if they don’t necessarily accept Medicare, they still can accept the PEBB insurance coverage.

Laura

Right. So, with that example might be with the Regents UMP with Medicare Part D plan. So, with that plan you’re likely going to want to see an in network provider because you’re going to get the best rate. If you see someone who’s in network. With the United Health Care plan for example, they do not require you to see someone in network. But you do have to pay upfront for that. So, you know, there’s kind of some variances there that you just want to be aware of when you’re utilizing the benefit.

Jenny

And then does someone need a referral from their primary care provider to see a massage therapist or naturopath? Yeah.

Laura

And again that’s going to be variable depending on the plan you have. Different plans have different requirements whether they need a referral or not. And of those services that we’re talking about, some of them may need referrals and some of them may not need referrals. I’ll talk really quickly about the vision and hearing benefit. So with vision, this is typically an allowance that you get per year for your glasses, hardware, things like that.

And then you typically have a set amount of visits that you can use per year for an eye exam. Some of the plans do use their own vision services, so you might need to see either an in-network provider or someone through if they have their own vision program. And then likewise with the hearing aid benefit, same thing. The some of the plans have their own hearing network.

United is an example there where you have an allowance for hearing aids per year, but you do have to purchase those through the United Hearing Network. And then some plans you don’t have to go through a network. You purchase the hearing aids and then you submit reimbursement. So again, it’s really important just to know what the variables are for your plan.

And you can certainly call your plan. If you love to read, you can go to our website at HCA. And you can look up what is called the Evidence of Coverage or the Certificate of Coverage for your plan. And that’s going to be lots of detail about every aspect of your benefits.

Seth

So, I think one of my takeaways is generally when we’re talking about these extra benefit coverage types or services, maybe the first best thing to do is talk to somebody from your plan. Yes. Who can I participate with and how will the cost be borne? Will this be a, I need to pay upfront and then I’ll get reimbursed?

Will the provider bill directly to the insurance provider? And then maybe it’s also a good idea to confirm that with the provider as well. Before you, you go in for those services to make sure that they understand what your insurance coverage options are. I think that’s probably especially true for people who live in areas where they may have to travel a little bit more for some of these services, or where the services aren’t as readily available.

Laura, are there are other things our listeners should, especially our since we’re talking just about retirees, I know I keep trying to like think about how this affects me as an active employee in the PEBB program. Are there other things retirees should know about? I can imagine a retiree who, a person who is not on Medicare. They had some service provider, they retire, and now they’re on maybe a different service provider as a retiree.

And they have Medicare. Are there things that they should be thinking about that might be different than when they were an active employee?

Laura

Yeah. So one of the interesting things, a couple of years ago, Medicare did start paying for some of these services, like I talked about before. They’re usually very limited. For example, chiropractor, there’s very specific procedures that they will cover. So Medicare has their own allotment. So sometimes what you’ll find is that you’ll go in and you’ll actually be utilizing the procedure that Medicare does cover.

So, the way it’s billed becomes important because first you get to use your Medicare allotment. And then you still have the allotment that’s available to you through your actual health plan. So sometimes there can be some confusion with how a provider needs to correctly bill the carrier. And in those cases, sometimes we can intervene just making sure the right parties are talking to each other.

But then of course, for small providers, sometimes the member can just encourage them to call their number that they have for that specific health plan. And the health plan should be able to coach them through what exactly they need to do in order to get that claim paid. And I think in general, the important thing is we want members to know that these benefits are included in their plan.

I hope this doesn’t sound too intimidating because unfortunately, it was hard for me to give great specific answers just because the plans do operate differently. But we just want people to know, hey, these benefits are here. They’re included in your plan. You might just want to make sure you know exactly how to use them, but they’re there for you, so you absolutely have those options for some extra stuff that you might not know you have.

Seth

I think I appreciate that context, because I do imagine that this could be one of the things that’s scary for a person as they’re approaching retirement. They’re used to having regular massage therapy services or physical therapy services for some chronic condition or whatever, and knowing that they are still going to have the opportunity for those services as part of their retiree coverage, when maybe they’re talking to a friend who isn’t on PEBB, who is now on Medicare and feels like they may have been shut out from some of those services.

So, I appreciate that. I think we have talked a lot on this podcast about everything insurance related is a little bit more complicated when you’re a retiree and trying to understand how those pieces work together is important. Which is why we’re glad you continue to join us on the podcast to help educate all of us a little bit more on how these work.

Jenny, do you have any other follow up questions?

Jenny

Yeah, so just as a reminder. So, some of those extra special services that we talked about acupuncture, naturopath. What about dietitian? Does that kind of fall under naturopaths?

Laura

No that’s typically separate. And again, some plans do have that benefit where there’s somebody that you can call and get some nutritional advice. There’s various programs within the plans. If you have specific diagnosis. So, if you’re someone who is living with diabetes or ESRD end-stage renal disease, those are the two that come to me immediately.

But there are some specific programs that you can enroll in and get kind of some additional support through your plan there.

Jenny

Okay. Thank you for that. Yeah.

Seth

Thank you, Laura, for sharing with us about these, additional benefits and maybe for some active employees, they don’t feel like additional benefits because they’re part of their current plan. But it is good to know that these are in addition to what a person would normally receive when they’re eligible for Medicare.

Laura

Absolutely. Thanks for having me.

[music outro]

Disclaimer

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References to any specific product or entity do not constitute an endorsement or recommendation. The views expressed by guests are their own, and their appearance on the program does not imply an endorsement of them or any entity they represent. Views and opinions expressed by DRS employees are those of the employees and do not necessarily reflect the view of DRS or any of its officials.