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.
When you are considering your options to cover the gaps in Medicare, i.e. deductibles, copays and coinsurance (yes, Medicare has all those), you might be looking at Supplemental or Advantage plans. There is a lot of confusion about how these types of plans differ and how they cover what Medicare doesn’t.
First, let’s take a look at Medicare Supplemental plans. These plans work similar to a PPO. With a regular PPO plan you can go to doctors in or out of network, but you generally pay more if you go out of network. Medicare Supplemental plans work a little differently because there are no networks. The only stipulation is that you must go to doctors that take Medicare whether they are primary care doctors or specialists. You can go to any doctor throughout the United States, including specialists, and be covered under your Supplemental plan. Supplemental plans are standardized, which means they have the same coverage regardless of carrier or region and are offered by private insurance companies. Premiums are determined by age and geographic location. You don’t need referrals from your primary care doctor to see a specialist. Supplemental plans do not include prescription drug coverage so you would have to purchase a separate Part D drug plan to cover your prescription medications.
Advantage Plans are also called Medicare Part C. Most Advantage plans work like an HMO. You must go to network doctors or you won’t be covered. They are specific to a certain geographic location, usually by county, and, in most cases, you must get a referral from your primary care doctor to see a specialist. Advantage plans are offered through private insurance companies and combine your Medicare Parts A, B and D (prescription drug coverage) into one plan. There are some plans that don’t have the Part D added if you have other drug coverage like Veteran’s Benefits. When you sign up for an Advantage Plan, you opt out of Original Medicare and the plan administers all your benefits. These plans may offer extra coverage like vision, hearing, and transportation to and from medical facilities, although some Supplemental plans are beginning to add these benefits as well. Advantage Plans include Special Needs Plans for people with certain chronic conditions like diabetes or heart disease and those that are eligible for both Medicare and Medi-Cal.
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.
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.
The department of Health and Human Services included in its terms and conditions for hospitals, clinics and doctors who receive federal emergency funding a clause which bans surprise billing. The clause states that, “for all care for a possible or actual case of COVID-19, the provider will not charge patients any more in out-of-pocket costs than they would have if the provider were in-network, or contracted with their insurance company.” The guidance further states, “HHS broadly views every patient as a possible case of COVID-19.”
Leaving the door open to allow everyone to be viewed as a potential coronavirus patient may not have been the intent of HHS. “Because the terms and conditions do not appear to be sufficiently clarified, there is a concern that there will be legal challenges around the balance-billing provision,” said health policy consultant, Rodney Whitlock.
Balance billing has been a health-care practice for years, allowing the industry broad control on how they bill patients. It is banned in many states, but there is no federal legislation on the matter. Jack Hoadley, a professor of health policy at Georgetown University, said the HHS terms for eligibility to receive CARES-ACT funding could address problems not explicitly sited in the relief legislation like patients billed for testing for COVID-19 when the results come back negative.
“The providers, the insurers, everybody else is going to need clarification, as well as, of course, all of us as potential patients,” Hoadley said. “That’s going to affect our willingness to seek testing or treatment.”
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%.