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.
If you have recently lost group employee health insurance coverage and are 65 or over and need to sign up for Medicare, you can submit your applications by FAX to help speed up the process. You must fill out an Application for Enrollment in Medicare Part B and also the Request for Employment Information forms.
The application can be downloaded at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS40B-E.pdf and the request for employment information form can be downloaded at https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/Downloads/CMS-L564E.pdf.
Be sure and indicate in the “Remarks” section of the application your desired effective date which will always be the first of the month, i.e., if you are applying in May, request an effective date of June 1. Also, if you cannot obtain your employer’s signature, the following alternatives will suffice.
State on the form “I want Part B coverage to begin (MM/YY)”
If possible, your employer should complete Section B.
If your employer is unable to complete Section B, please complete that portion on behalf of your employer without your employers signature and submit one of the following forms of secondary evidence:
income tax form that shows health insurance premiums paid;
W-2s reflecting pre-tax medical contributions;
pay stubs that reflect health insurance premium deductions;
health insurance cards with a policy effective date;
explanations of benefits paid by the GHP or LGHP; or
statements or receipts that reflect payment of health insurance premiums.
Once completed, the forms can be faxed to Social Security at 1-833-914-2016.
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.
IRMAA stands for Income-Related Monthly Adjustment Amount, and what it means is that you are being charged more on your Medicare Part B premium and your Medicare Part D Drug Plan premium based on your income. If your Modified Adjusted Gross Income, or MAGI, is over $87,000 as a single person or over $174,000 as a couple, you will have this surcharge added to your monthly premiums. It goes up incrementally as your income rises to an additional $347.00 on Part B and $76.40 for Part D if you are in the highest brackets (above $500,000 for individuals or $750,000 for couples). The amount is added to the standard premium which is $144.60 for 2020. The good news is that it doesn’t affect what you pay for a supplemental or advantage plan.
Only about 5% of people on Medicare pay the extra charge which was implemented on Part B in 2003 and on Part D in 2011 as a way to save the federal government money on the burgeoning cost of the Medicare program. What can be even more frustrating is that Medicare looks at income tax records from two years prior. That means if you sign up for Medicare in 2020, your IRMAA will be based on your 2018 tax records. Most people are making less money once they retire and go on Medicare, so what can you do if you are in this situation? You can appeal the extra charges to Medicare directly. By filing form SSA-44, Medicare may adjust the amount you owe to reflect your current income levels. If you don’t appeal, your income is re-evaluated yearly, so you won’t be paying the higher premiums forever if your income does decrease.
If you’re approaching Medicare eligibility, it is important to know the various times to sign up for this important milestone. Below are the enrollment periods that will help you determine what your eligibility is or whether you need to sign up for Medicare at all:
Annual Enrollment Period – Period every year between October 15 and December 7 when you can change your Medicare Advantage Plan or Prescription Drug Plan.
Open Enrollment Period – Additional period of time from January 1 through March 31 when you can change your Medicare Advantage Plan. You can also return to Original Medicare with or without a drug plan.
Retirement/Loss of Group Health Insurance – Period of time once you retire or lose creditable group coverage to sign up for Medicare and a Supplemental, Advantage Plan and/or Part D Drug plan.
Supplemental Plan Birthday Rule – Period that allows you to change your Supplemental plan that begins 30 days before your birthday up to 60 days after your birthday.
Special Enrollment Period – Period of time to change your Medicare Advantage plan or Part D drug plan because of a life event, i.e., moving out of service area, qualifying for Low Income Subsidy. If you are still actively working and have a creditable (as good as Medicare) group employee health insurance plan, you may be able to keep the plan until you retire and delay signing up for Medicare without incurring penalties. Check with your benefit’s administrator to see if this is a viable option for you.
While most peoples’ health insurance costs go down when they sign up for Medicare, many are surprised that Medicare doesn’t pay 100% of their medical expenses. There are deductibles, copays, and coinsurance which can add up to hundreds, if not thousands, of dollars per year of out-of-pocket costs if you have Medicare alone.
How can you bridge the gaps and keep more money in your pocket? There are basically two ways you can go. Below is an explanation of each:
Medicare Supplemental Plans – You remain in Original Medicare and can go to any doctor who takes Medicare throughout the United States. Your plan travels with you, and you do not have to get a new plan if you move out of state. You don’t need to get referrals to see a specialist. If you want prescription drug coverage, you would have to purchase a stand-alone Part D plan to go with your Supplemental Plan since none of these plans cover prescription drugs.
Medicare Advantage Plans – You opt out of Original Medicare and go with a private company that combines Parts A, B and D into one plan (which is also called Medicare Part C). Most plans require you to see network doctors and get referrals to see a specialist. Some plans exclude Part D if you have other drug coverage such as VA benefits. Advantage Plans include Special Needs Plans for people with certain chronic conditions and Medi-Medi plans for those who qualify for both Medicare and MediCal.