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.

Seven companies have won grants from the National Institutes of Health (NIH) to develop better and faster testing to help fight the spread of the Coronavirus.  Six of the seven companies are here in California.     

“This is a very substantial investment to try to speed up the availability of COVID-19 testing to try to deal with this pandemic,” said Francis Collins, NIH Director, during a virtual briefing to reporters.   

Mammoth Biosciences, Inc. and Fluidigm Corp. are two San Francisco-based companies that will get a portion of the $1.5 billion in emergency funding provided by Congress back in April. Mammoth will base its testing using CRISPR, DNA editing technology that can pinpoint a specific location in a genetic code. Fluidigm has developed a saliva test that could be a game-changer for ease and rapid testing.        

Quidell Corp. and Mesa Biotech, headquartered in San Diego, also received funding.  Quidell’s new antigen test can get a result in as little as 15 minutes, and Mesa’s hand-held device can produce results in as little as 30 minutes.

Helix OpCo LLC is located in San Mateo and plans to ramp up processing to up to 100,000 nasal swabs by year’s end using next generation sequencing, and Ginko Bioworks in Boston is scaling up to do the the same. The final company, Talis Biomedical located in Melo Park, California has a test which uses a multiplexed cartridge to detect the virus with results in 30 minutes.

Trump recently signed four executive orders in hopes of curbing high drug prices in the United States. One of the orders targets how Medicare reimburses physicians for the administration of medications in hospital or office settings which is covered under Medicare Part B. The standing rule is that doctors can charge up to an additional 6% of the average sales price of a medication, which would incentivize physicians to use higher cost drugs. Trump’s order reduces the amount that can be charged to the lowest price paid by industrialized nations under an International Pricing Index.

Another executive order revamps the rebate rule which allows pharmacy benefit managers to pocket these payments instead of passing these discounts to the consumer. Under the order, patients would receive the savings instead of these middlemen, who would receive a fixed dollar amount instead of a percentage of the price of the medications.

Obtaining low-cost drugs from other countries is addressed in an order which allows FDA-approved medications to be imported, and the final order targets lowering the cost of insulin and epinephrine. Insulin prices have more than doubled in the last five years and the average cost of a two-pack EpiPen continues to soar. The order would require Federally Qualified Health Centers who serve low-income patients to pass on savings to their consumers instead of pocketing the discounts made available to them under the federal drug discount program or 340B.

If you have Medicare, you are considered among the high-risk groups for having complications should you get the COVID-19 virus, so knowing how you are going to be covered should you get sick is important. Utilizing the services you are entitled to can help keep you and your loved ones healthy and safe during these difficult times.

Medicare covers COVID-19 lab tests with no out-of-pocket costs, so if you feel ill, get tested. If you think that you have already had the virus, Medicare also covers the FDA-authorized antibody test. Once there is a COVID-19 vaccine, that will be covered as well.

Medically necessary hospitalizations are covered, but you will pay any deductibles, copays or coinsurance applicable to your stay. If you have a Medicare Supplemental or Advantage plan, the plan may pay all or some of these associated costs. Advantage plans may also pay for costs like meal delivery or medical transportation.

Under the 1135 Waiver implemented in March by the Coronavirus Preparedness and Response Supplemental Appropriations Act, the Centers for Medicare and Medicaid have expanded the availability and use of telehealth services to allow evaluation and management visits with your doctor, mental health counseling and preventative screenings. These “virtual check-ins” are brief communications with your health practitioner for an issue that wasn’t related to a medical visit within the previous 7 days and does not lead to a medical visit within the next 24 hours or next available appointment. Verbal consent by you and documentation by your doctor is needed to initiate these services. Online patient portals can also be used with prior consent as well.

If you do go to the doctor, be ready for some changes many practices have implemented to minimize exposure to the virus. You might have to wait in your car prior to the start of your appointment, have your temperature taken, wear a face mask, and social distance.

 In an effort to address the ramifications of unprecedented job loss due to COVID-19, Covered California is extending Open Enrollment to sign up for health insurance through July 31.     

“The ongoing challenges of COVID-19 make it vital that we help Californians get into and stay in Medi-Cal and Covered California health coverage.  The goal is to make it easier to access needed care and services during these difficult times,” said Will Lightbourne, director of the Department of Health Care Services.   

The Open Enrollment also applies to off-exchange plans.  Medi-Cal renewal reviews are also being suspended indefinitely in light of the pandemic to assure those receiving assistance will not lose coverage.  New state subsidies that went into effect at the beginning of the year may help more people qualify for premium assistance.   Depending on where you are on the Federal Poverty Level chart determines the amount of assistance you will get.   While most states cap the amount at 400% of the FPL, California has increased it to 600% of the FPL.

While the worldwide pandemic is currently affecting everyone’s daily lives, you have to wonder what permanent changes this life-altering event will have on the healthcare system. The roles of hospitals and primary care doctors will likely be altered in the new normal of “touchless” care.

Public health policy changed drastically in the wake of the 1918 Spanish Flu Pandemic which claimed between 50 and 100 million lives. Many countries moved to a more socialistic approach to medicine while the United States embraced a solution which offered health insurance through employers. In 1919 an international bureau for fighting contagious diseases was formed, the precursor to the World Health Organization.

It took years for the U.S. to implement systems like Medicare, Medicaid and the Affordable Care Act, but the suddenness of COVID-19 has forced the government to act with an impetus born of necessity. The Centers for Medicare and Medicaid quickly expanded the access to telehealth for its members, and a recent Gallop poll showed virtual visits nearly doubled from March to mid-May. Telemedicine is sure to be one of the tools that will be widely used in the future by the healthcare system.

While many hospitals are struggling to staff emergency rooms which is often the first point of contact for those seriously ill from COVID-19, other healthcare services are struggling to survive. Physicians have seen a vast decrease in patient visits because of widespread fear of getting the illness. Elective procedures have been postponed or canceled because of the same fear. Experts say the “fee-for-service” model of doctors billing for each service performed is out-dated and instead should be focused more on “lump-sum” payments tied to quality of patient care. It would give physicians more incentive to expand services like telehealth and patient education instead of focusing on seeing as many patients as possible which the “fee-for-service” model promotes.

The pandemic has also highlighted the inequality of healthcare in minority populations with these groups reporting higher incidence of hospitalization and death. Future governmental policy will need to address how to better care for the people most at risk. Data collected during the pandemic can be used to focus funding and allocate resources to manage risk in these vulnerable populations.

Telemedicine is booming during the coronavirus pandemic. People are afraid to venture out of their homes to seek care at doctors’ offices, urgent care facilities and hospitals for fear of exposure to the virus. But sometimes consulting with a physician is necessary to make sure you stay healthy during these stressful times. Putting off or ignoring physical symptoms can worsen a condition that might otherwise be easily treated with the right care.

The best place to start when considering telemedicine is your insurance plan. Many plans already have this benefit in place or have expanded its use during this crisis. The Centers for Medicare and Medicaid have implemented new guidelines to expand access to virtual medical visits. If your insurance doesn’t offer telemedicine, you can use one of the many telehealth companies like Teledoc, LiveHealth or Doctor On Demand. Some require insurance and most will have a copay or set fee per virtual visit.

As at a regular doctor’s office, you will be required to disclose your medical history, including the medications you currently take. Prepare yourself before the visit by making a list of your symptoms, writing down any questions you may have, and have your pharmacy information on hand should the doctor need to call in a prescription for you. Not everything can be checked at a virtual visit, and the doctor may require to see you in person, or if your symptoms are severe, he or she may have you go to the nearest emergency room for treatment.

The IRS recently announced it is allowing mid-year changes to health-care plans sponsored by employers, including changes in flexible spending accounts (FSA’s) which lets employees use pre-tax dollars for health expenses.

The new rules will give workers impacted by the coronavirus pandemic options to alter their previous health-care choices that were made prior to the COVID-19 outbreak. They can change the amount of contribution to an FSA to free-up money that can be used for other expenses, elect coverage if they previously declined coverage, or make changes to the type of plan they have, i.e., going from an individual to a family plan.

It is up to each employer’s discretion to offer these changes since it is not a requirement, but many employers have already allowed employees to take loans and/or distributions from their retirement plans to help them during the pandemic. It is important to note that funds that have already been deducted from paychecks and put into FSA accounts will not be impacted; only future contributions would be affected.

Other changes the IRS made include expanding the eligible items for reimbursement from an FSA account and increasing the carry-over amount from one year to the next from $500 to $550. To view the IRS Notice 2020-29, visit: https://www.irs.gohttps://www.irs.gov/pub/irs-drop/n-20-29.pdfv/pub/irs-drop/n-20-29.pdf

The Supreme Court is slated to hear arguments to invalidate the Affordable Care Act signed by President Barack Obama in 2010 as early as this fall. The Trump Administration maintains that the individual mandate requiring health insurance is unconstitutional, and therefore, all provisions of the law must be struck down. Texas and other Republican states initiated the dispute when they sued after Congress eliminated the tax penalty for those going without health insurance.

Attorney General William Barr has recently appealed to the administration to reconsider its stance, letting part or all of the law stand in the midst of the Coronavirus Pandemic. Along with Health and Human Services Secretary, Alex Azar, Barr contends that striking down the law could disrupt the health care of millions and cause others to lose their coverage or go without entirely.

The insurance exchanges that implement the Affordable Care Act (ACA) could be a safety net during the pandemic, providing subsidies and Medicaid for those who have lost employer-based coverage. With an unemployment rate approaching 15%, a major change in health insurance policy would add another burden to an already overwhelmed population.

Although the case will be heard by the Supreme Court this fall, a decision would not likely be announced until 2021. The law has remained intact throughout the litigation, with the exception of the individual mandate which was eliminated in January 2019. Other states have implemented their own laws to preserve key aspects of the ACA as California has done, mandating that its residents have health insurance coverage or face a penalty as well as expanding the parameters to offer more people the ability to qualify for subsidies.

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.