Background:
Calvin Grobe, a lifelong Iowan, passed away on August 9, 2023, at the age of 83. In August 2020, at age 80, Calvin applied for a Medicare Supplement (MedSupp) insurance plan. These plans are designed to cover the “gaps” in Original Medicare — the 20% of costs not paid by Medicare, and the deductibles, coinsurance, and copays that can add up quickly, especially for chronic conditions.
The Application Process:
By 2020, Calvin was taking Aricept (donepezil), a drug almost exclusively prescribed for Alzheimer’s disease and dementia-related cognitive decline. As part of the underwriting process, the insurer used IRIX, a prescription history analysis tool. IRIX flagged the Aricept prescription in red, signaling a high-cost chronic condition to the underwriting team.
Why the Red Flag Mattered:
- Alzheimer’s is progressive and incurable, with substantial projected lifetime costs.
- MedSupp plans can legally deny applicants outside of their guaranteed issue period (typically the first 6 months after enrolling in Medicare Part B).
- In Calvin’s case, at age 80, underwriting rules allowed the insurer to decline the application based solely on the Aricept prescription as a proxy for his health status.
The Outcome:
Calvin’s application was denied. While he still had Medicare coverage, he remained without the financial buffer a MedSupp plan could have provided. That meant greater exposure to out-of-pocket costs for the remainder of his life, just as his healthcare needs were likely to grow.
The Bigger Problem:
This case highlights how the intersection of predictive risk tools, legal underwriting rules, and prescription data can lock people out of coverage at the moments they need it most.
- Legal: The denial complied with federal and state insurance regulations.
- Impactful: The decision was based on a single prescription, without room for nuance or consideration of quality-of-life goals.
- Preventable: With better policy protections or plan design, people like Calvin could secure needed coverage even after a late-stage diagnosis.
609 Health’s Perspective:
At 609 Health, this story underscores our mission: to ensure healthcare data and decision-making tools don’t just identify risk — they enable solutions. Systems like IRIX should be used to find ways to cover people and coordinate care, not to automatically exclude them.
