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.
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.
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.
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.