Medicare can be very confusing for those newly eligible, and often I see the same issues coming up for those who are trying to navigate the Medicare maze.  Here are few points to try and help clarify the process.

     Many confuse the Parts of Medicare with the various Supplemental Plans available to them to fill the gaps in Medicare.  The reason is that some of the Supplemental Plans have the same letter name as parts of Medicare.  You have Parts A, B, and C with Medicare, but these are also names of Supplemental Plans that go with Medicare.  Basically, Medicare has Part A – Hospital Coverage, Part B – Medical or Doctors’ Coverage, Part C – Medicare Advantage Plans, and Part D – Prescription Drug Coverage.  You also have Plans A, B and C which are Supplemental Plans that cover the gaps in Medicare.
     A Medicare Advantage Plan is not the same as a Medicare Supplemental Plan. When you sign up for a Medicare Advantage Plan, you are signing up for Part C with Medicare, even though these plans are administered through private insurance companies.  The insurance companies handle all costs associated with your care, but are subsidized by the Medicare program.  These plans are usually HMO’s that require referrals to see specialists, and you must use Network providers in your service area to be covered.  Supplemental Plans are PPO’s with no Network restrictions.  However, you must use providers that take Medicare.
     Cobra is not considered creditable coverage for Medicare.  If you lose your job and are Medicare-eligible, if you go on Cobra, it is not considered creditable coverage, which means you could be charged a penalty on your Medicare Part B and Part D premiums once you do sign up for Medicare. 
     If your employer has 20 or more employees, you can remain on your employee group plan (as well as your dependents) if you are actively working, even though you are eligible for Medicare.  The prominent word here is actively working, which means you cannot be on Cobra or laid-off from work. 
     Higher earners pay more for their Medicare Part B premium and their Medicare Part D premium.  If you make over $88,000 (as a single person) or over $176,000 (as a couple), you will pay more for your Part B and Part D premiums.  It is called IRMMA (Income-Related Monthly Adjusted Amount), and it increases in increments based on income level.

As the Biden Administration works with FEMA to open 100 COVID vaccination sites across the United States, there is still much confusion over who is eligible to get the vaccine and where they go to schedule an appointment. The two federal sites in California that have already opened are located at Oakland-Alameda Colosseum in the Bay area and California State University in Los Angeles.

To find out if you are eligible to receive a vaccination, you can visit the California state site at https://myturn.ca.gov/. Riverside County’s COVID website is https://rivcoph.org/coronavirus. Orange County’s site is https://occovid19.ochealthinfo.com and the San Diego County site is https://www.sandiegocounty.gov/coronavirus.

As well as these county sites, appointments can be made at certain Albertsons, Rite Aid, Ralphs and Pavilions pharmacies. Blue Shield and Kaiser Permanente have been contracted with the state to help manage the vaccine rollout. Those who are eligible currently, according to state guidelines, are those in phase 1A (healthcare workers and long-term care residents) and 1B (those 65 and older, agricultural and food workers, educators and emergency service personnel). The next phase, which includes those 16 to 64 with high-risk underlying conditions is scheduled to open on March 15.

A Medi-Medi plan, also often referred to as a dual-special-needs plan or “look alike” plan, is a type of Medicare Advantage plan for people who qualify for both Medicare and Medicaid or Medi-Cal in California. Medicare is the primary payer on these types of plans with Medi-Cal being the secondary payer. You must go to doctors who accept both Medicare and Medi-Cal, and your share of cost is determined by your asset level. In California, to qualify in 2020 as a single person, your asset level is at $2,000 or below ($3,000 or below for couples). There are many things that are not included in your asset level like your primary residence, household items, pre-paid burial expenses and your car.

The advantages of having a Medi-Medi plan are that they coordinate your care with a provider network and often include extra benefits such as vision, dental and transportation services. You do, however, have to use the doctors and specialists in the plan’s network to be covered (except in cases of emergency). These plans are provided by private insurance companies, and the benefits and costs can vary from company to company. Prescription drugs are included in the plan with copays at no more than $1.30 for generic drugs and no more than $8.95 for brand drugs. If you pay no share of cost, your copays would be $0 for your medications.

You will automatically be enrolled in Medi-Cal if you qualify and sign up for Supplemental Security Income (SSI) through Social Security. You may qualify, as well, if you don’t get SSI, but you must contact your Medi-Cal county office to see if you meet eligibility requirements. If you are considering a Medi-Medi plan, be sure and check that your current doctors are in the plan’s network (if you wish to remain with them), and that your medications are in the plan’s formulary. You can also apply for one of these plans if you become newly eligible for assistance or during the Annual Enrollment Period from October 15 to December 7.

Balance Billing is a common problem when you go to out-of-network doctors not covered or partially covered by your health insurance. The consumer is charged for these costs in bills that could come weeks or months after the initial visit or procedure.

There are steps you can take, however, to mitigate these surprise medical bills.  First, be sure to check your Explanation of Benefits (EOB) which usually comes with the bill.  Check the dates to make sure the service you are being billed for is accurate and which services were actually performed by out-of-network providers.  Be prepared.  Get an itemized copy of your bill and know what the “usual” charge is for the procedure.  Sites like FAIR Health can help you determine what costs are common for medical procedures in your area.  Call the provider and ask to speak to someone in billing who can assist you with the bill.  You can also write to your insurer and request that they cover a portion or all of the balance billing.

Ultimately, one of the best ways to avoid balance billing is to make sure you go to network providers.  Call your insurer in advance, if possible, to make certain all your care is being handled by in-network doctors, from the surgeon to the anesthesiologist.  Make sure all lab work and tests needed in preparation for the surgery is covered as well.  

If you failed to meet the January 31 open enrollment deadline to enroll in a health insurance plan for 2020, you might still be able to get coverage this year. Covered California is allowing those who didn’t know about the new mandate to have coverage to sign up by April 30. Not knowing about the new law is considered a qualifying event. You will have to mark a box on the application saying you did not know that there would be a penalty assessed if you do not have health insurance coverage in 2020.

Enrollment increased for the first time in three years, according to statistics from the state-run marketplace, most likely due to the new tax to be implemented on those going without insurance. “I encourage everyone who does not have qualifying health insurance to take advantage of the special enrollment period,” State Controller Betty Yee said in a press release. “I like signing tax refund checks, not assessing penalties.”

While the federal government under the Trump Administration has been slashing its advertising budget for the federal marketplace, California has done just the opposite, spending nearly $121 million on advertising. The state has also increased the length of open enrollment, giving residents longer to sign up than in other states. These factors resulted in an increase in enrollment in California by 1.6% compared to a decline in the federal marketplace of 0.5%.