Here are a few things to consider when getting ready to apply for insurance through Covered CA:
- Your tax household: Who will be on your tax return for the current year? Did you get married, have a child, or will you lose a dependent?
- Household income: Will you be receiving a year-end bonus, severance pay or a pay raise?
- Other Income: 401K withdrawals (taxable), property income or Social Security Retirement or Disability Income.
- Federal Poverty Level: Depending what your FPL is you may qualify for additional help or no help at all. Did you receive premium assistance and are contemplating withdrawing from your 401K? Consider what your FPL will be once you do so. You can end up having to pay back all of your premium assistance. Yikes
Now, more than ever, is the time to make sure you have access to healthcare. It starts with having the appropriate insurance coverage, or Medi-Cal if your income qualifies , and being connected with a good IPA or Medical Group in your local area.
Testing and treatment for the COVID-19, the disease caused by the novel Coronavirus, has become easier and you won’t experience denial of treatment. However, eventually medical bills will come due if you don’t have a health plan and you may be paying unexpected bills for the treatment of this illness. Health insurance plans are now covering testing and treatment with no out of pocket cost to you at least until the end of May 2020. So, if you believe you have COVID-19 symptoms, call your primary care doctor to test whether you are positive. Even if you test positive by the end of May, you will incur no out of pocket expense when treated for it after the end of May.
We can assist in enrolling in the health plan appropriate to you or Medi-Cal. If you have any questions about coverage, please contact us at 562-343-7301 or email us at firstname.lastname@example.org.Read More
When you become Original Medicare qualified (typically when you turn 65 years old) you will find that you will not have 100% coverage. You can exercise a couple of options to fill that gap. One option is the Medicare Supplement option. We will discuss this in a separate post. The other option is enrolling in a Medicare Advantage Plan. So, what is the “advantage” of the latter option? First, a summary of what Original Medicare is.
Original Medicare has two parts, Part A and Part B.
Part A, also known as Hospitalization coverage. The gap in Part A is a deductible is $1364 for every 60 days. Also there is a $341/day copay starting the 61st day of hospitalization.
Original Medicare Part B gap is the $185 annual deductible and, after paying the deductible, 20% coinsurance with no maximum out of pocket. Unlike traditional health insurance where there is a dollar amount you spend and after you hit it the plan pays 100%, Part B does not have this benefit.
Another gap with Original Medicare is that it does not have prescription drug plan coverage. This is offered by private health insurance companies for an additional premium.
Is Medicare Advantage Right For You?
As with anything, it all depends if a Medicare Advantage Plan is right for you. Here are some items to consider when comparing Original Medicare and getting a Medicare Advantage Plan.
- You may like the flexibility of seeing any provider or going to any facility, so long as they accept Original Medicare and assignment as payment from Medicare in full.
- If you choose the Original Medicare and Medicare Supplement route you are responsible for coordinating or your care and records with the various providers and specialist you see with Original Medicare.
- When you sign up for a Medicare Advantage Plan, it takes over Part A and Part B from Original Medicare and becomes the primary payer. Instead of the deductibles and large copays, you will have either no or small copays. Medicare Advantage Plans also have a Maximum Out of Pocket on an annual basis so no matter what expensive illness or injury you may have, you can be sure that you will not suffer a financial catastrophe
- Medicare Advantage Plans include a Part D prescription drug plan. Many plan have zero premium.
- There are many additional benefits included with a Medicare Advantage Plan like
- Dental coverage
- Vision Coverage
- Hearing Coverage
- Gym Membership
- Over-the-counter allowance
- Overseas coverage
There are many plans available. Physician networks and coverage vary from plan to plan. We can help you pick the plan that is right for you. Also with the plans we represent, we help you keep your doctor. We are medicare brokers who work for you and not the insurance companies. Contact us for a no-cost consultation to find a plan that is right for you.Read More
My team and I often discuss the issues that we hear first-hand from Medicare beneficiaries. We are fortunate to have a community of Medicare beneficiaries that trust us with their Medicare journey ( and the bumps on the road that come with it). In our community, one question that comes up is what options are available to people who do not qualify for free Medicare part A? If you are reading this, you are likely looking for an answer yourself. Here’s what you can do if you don’t qualify for premium free Part A.
Defining Premium Free Medicare Part A
The reality is, no part of Medicare is free. Though, the reason we talk about premium free Part A is that most Americans pay Medicare payroll, or FICA, Taxes during their working years, providing them the opportunity to enjoy no additional Part A premiums after enrolling in Medicare. You qualify for premium free part A if:
- You are 65 or older ( a few exceptions apply) and you and your spouse have paid FICA for at least 10 years
- You are eligible for Railroad Benefits
- You receive Social Security Disability Income
- After a 24 month waiting period, you are qualified to enroll in Medicare
Free Medicare Part A Through Your Spouse
If you don’t qualify because you did not accumulate the required time in paying FICA, that doesn’t mean you have to pay Part A premiums. If you are married, you may qualify because your spouse has had employment and paid at least 10 years of FICA taxes. Here are a few things to note if you think you qualify through your spouse
- Your spouse who paid Medicare taxes must be at least 62 years old at the time you are 65 years old and are qualified to apply for Medicare
- Your marital status matters
- Married-you must be married for at least 1 year prior to receiving benefits
- Divorced-If you were married for at least 10 years and haven’t remarried, you are eligible through your former spouse.
- Widowed-if you were married for at least 9 months and haven’t remarried, you will be eligible.
Medicare Part B
You have to pay premiums for this benefit regardless of how many years you have paid FICA or whether you paid FICA at all. The premium is $135.50 per month in 2019 and is indexed higher based on income. You can apply for this benefit without applying for Part A. When you do it also entitles you to apply for a Part D prescription drug plan.
Paying Part A out of pocket
If you haven’t met the requirements to get premium free Part A you will have to pay a premium in addition to the Part B premium.
- If you have less than 30 quarters ( or 7 years, 2 months) paying FICA, Part A premiums are $437/month
- If you have at least 30 quarters but not the full 40 quarters paying FICA, Part A premiums are $240/month
What if I don’t sign up for Part A?
If you decide not to sign up for Medicare during your Initial Enrollment Period, you will be subject to late enrollment penalties if you decide to sign up later.
- For Part A, the penalty is 10% of the monthly premium for twice the number of years you wait to enroll. For example, if you waited a year to enroll in Part A, you will pay a penalty for two years. However, once you qualify for Free Part A, the penalty goes away.
- For Part B, the penalty is 10% of the monthly premium for every year you do not sign up. Also you will pay this penalty for your lifetime. For example, if you wait two years before applying your penalty will be 20% of your monthly premium for as long as you have Part B.
- There is an exception to the penalties.
- For Part A and B, you do not have to sign up so long as you have creditable coverage from your employee benefits. When you leave your employer, you have 8 months to sign up for Part A and B without any penalty.
- This is not a true exception, but if you qualify for Full Benefits Medi-Cal, Part B, and in some cases Part A, premiums, including the penalties will paid by Medi-Cal.
A way to avoid the high Part A premiums is to not sign up for it until you accumulate 40 quarters of paying FICA. It would be appropriate to sign up just for Part B during your Initial Enrollment Period to avoid the penalty. When you are enrolled in Part B you can enroll in Part D prescription drug coverage. This options will give you medical coverage, but not Hospitalization coverage.
Another way to avoid the high Part A premiums.
So long as you don’t qualify for free Part A, you are eligible to sign up for Covered California for you health insurance and, if you qualify, receive Premium Tax Credits and/or State Tax Subsidies to help pay for a portion of your premium. This option will give you comprehensive medical coverage.
So, if the out-of-pocket premiums seem big now – they will only grow bigger if you choose not to enroll at the appropriate time or the appropriate plan. Contact our office to discuss your optionsRead More
Even if you have health insurance there are still out of pocket expenses you will have especially when you undertake a major medical procedure. Here’s a case study of what a planning scenario looks like and, even with a good plan, what pitfalls there are in the medical system. Let me point out that it’s still much better to have health insurance than to not have it at all.
Rachel Bluth, Kaiser Health News
From a planning perspective, Wolfgang Balzer is the perfect health care consumer.
Balzer, an engineer, knew for several years he had a hernia that would need to be repaired, but it wasn’t an emergency, so he waited until the time was right.
The opportunity came in 2018 after his wife, Farren, had given birth to their second child in February. The couple had met their deductible early in the year and figured that would minimize out-of-pocket payments for Wolfgang’s surgery.
Before scheduling it, he called the hospital, the surgeon and the anesthesiologist to get estimates for how much the procedure would cost.
“We tried our best to weigh out our plan and figure out what the numbers were,” Wolfgang said.
The hospital told him that the normal billed rate was $10,333.16 but that Cigna, his insurer, had negotiated a discount to $6,995.56, meaning his 20% patient share would be $1,399.11. The surgeon’s office quoted a normal rate of $1,675, but the Cigna discounted rate was just $469, meaning his copayment would be about $94. (Although the Balzers made four calls to the anesthesiologist’s office to get a quote, leaving a voicemail, no one returned their calls.)
Estimates in hand, they budgeted for the money they would have to pay. Wolfgang proceeded with the surgery in November, and, medically, it went according to plan.
Then the bill came.
The Patient: Wolfgang Balzer, 40, an engineer in Wethersfield, Conn. Through his job, he is insured by Cigna.
Total Bill: The estimates the Balzers had painstakingly obtained were wildly off. The hospital’s bill was $16,314. After the insurer’s contracted discount was applied, the bill fell to $10,552, still 51% over the initial estimate. The contracted rate for the surgeon’s fee was $968, more than double the estimate. After Cigna’s payments, the Balzers were billed $2,304.51, much more than they’d budgeted for.
Service Provider: Hartford Hospital, operated by Hartford HealthCare
Medical Procedure: Bilateral inguinal hernia repair
What Gives: “This is ending up costing us $800 more,” said Farren, 36. “For two working people with two children and full-time daycare, that’s a huge hit.”
When the bill came on Christmas Eve, the Balzers called around, trying to figure out what went wrong with the initial estimate, only to get bounced from the hospital’s billing office to patient accounts and finally ending up speaking with the hospital’s “Integrity Department.”
They were told, “a quote is only a quote and doesn’t take into consideration complications.” The Balzers pointed out there had been no complications in the outpatient procedure; Wolfgang went home the same day, a few hours after he woke up.
The couple appealed the bill. They called their insurer. They waited for collection notices to roll in.
Hospital estimates are often inaccurate and there is no legal obligation that they be correct, or even be issued in good faith. It’s not so in other industries. When you take out a mortgage, for instance, the lender’s estimate of origination charges has to be accurate by law; even closing fees — incurred many months later — cannot exceed the initial estimate by more than 10%. In construction or home remodeling, while estimates are not legal contracts, failure to live up to them can be a basis for liability or “a claim for negligent misrepresentation.”
In this case, Hartford Hospital produced an estimate for Balzer’s laparoscopic hernia repair, CPT (current procedural terminology) code 49650.
The hospital ran the code through a computer program that produced an average of what others have paid. Cynthia Pugliese, Hartford HealthCare’s vice president of revenue cycle, said the hospital uses averages because more complicated cases may require additional supplies or services, which would add costs.
“Because it was new, perhaps the system doesn’t have enough cases to provide an accurate estimate,” Pugliese said. “We did not communicate effectively to him related to his estimate. It’s not our norm. We look at this experience and this event to learn from this.”
Efforts to make health care prices more transparent have not managed to bring down bills because the different charges and prices given are so often inscrutable or unreliable, said Dr. Ateev Mehrotra, an associate professor of health care policy and medicine at Harvard Medical School.
“The charges on there don’t make any sense. All it does is, people get pissed off,” Mehrotra said. “The charge has no link to reality, so it doesn’t matter.”
Resolution: “Because I roll over more easily than my wife does, I’m of the mindset to pay it and get done with it,” Wolfgang said. “My wife says absolutely not.”
Investigating prices, dealing with billing departments and following up with their insurer was draining for the Balzers.
“I’ve been tackling this since December,” Wolfgang said. “I’ve lost two or three days in terms of time.”
For the Balzers, there’s a happy ending. After a reporter made inquiries about the discrepancy between the estimate and the billed charges — six months after they got their first bill — Pugliese told them to forget it. Their bill would be an “administrative write-off,” they were told.
“They repeatedly apologized and ended up promising to adjust our bill to zero dollars,” Wolfgang wrote in an email.
The Takeaway: It is a good idea to get an estimate in advance for health care if your condition is not an emergency. But it is important to know that an estimate can be way off — and your provider probably is not legally required to honor it.
Try to request an estimate that is “all-in” — including the entire set of services associated with your procedure or admission. If it’s not all-inclusive, the hospital should make clear which services are not being counted.
Having an estimate means you can make an argument with your provider and insurer that you shouldn’t be charged more than you expected. It could work.
Laws requiring some degree of accuracy in medical estimates would help. In a number of other countries, patients are entitled to accurate estimates if they are paying out-of-pocket.
Most patients aren’t as proactive as the Balzers, and most wouldn’t know that the hospital, surgeon and anesthesiologist would each bill separately. And most wouldn’t fight a bill that they could afford to pay.
The Balzers say they wouldn’t have changed their medical decision, even if they’d been given the right estimate at the beginning. It’s the principle they fought for here: “There’s no other consumer industry where this would be tolerated,” Farren wrote in an email.Read More
So you’re turning 65 and closing in on being qualified for Original Medicare. You, however, are actively employed and are covered by your Employer’s Group Health coverage. You now have options to determine the most cost-effective way to get health coverage with the best benefits.
There are a few things to consider when you review your options. Employer size is important in determining what options you can exercise. Employees are defined by who works fulltime or part-time over the course of 20 weeks in the current or preceding year.
If your employer has 20 or more employees your group health coverage is the primary payer (they pay first) and Original Medicare is secondary. This is important to know so you can weigh out premium and coverage questions. Even if Part A is free, Part B has a $135.50/month premium in 2019. You have to look at your contribution to your employee group health coverage and compare it. Because your employee benefit is primary you can exercise not to enroll in Part B and pay Part B premiums. When you leave employment, you will have up to 8 months from the time your employee benefits stop to enroll in Part B without paying a Late Enrollment Penalty.
If your employer has less than 20 employees, Original Medicare is the primary payer and the group plan is the secondary payer. This means that for every provider visit, you must present your Original Medicare Red, White, and Blue card along with your group health insurance ID card. It is important to enroll in both Parts A and B. As with plans with over 20 employees there are premium and coverage options to review.
Whether your employer sponsored plan is primary or Medicare is primary, you should consider what your out-of-pocket expenses will be when you compare the two. If your employer’s only offering is Bronze plan, which has a $6300 deductible, you may opt to sign up for Original Medicare Parts A and B, then sign up for a Medicare Supplement plan or a Medicare Advantage Plan. You will pay less out-of-pocket expenses for medical treatment when you exercise this option.
Turning 65 years old is not the only way you can qualify for Original Medicare. If you have End Stage Renal Disease (ESRD) you will qualify for Original Medicare regardless of how old you are. Your eligibility starts 4 months after you enroll so the primary payer for your treatment and dialysis is your group health plan. Even after the 4th month when Original Medicare is effective, there is a 30 month coordination period between Original Medicare and your group health plan in which the group plan is the primary payer. After the 30 month coordination period, Original Medicare becomes the primary payer regardless of the number of employees an employer has covered under the group plan.
One consideration, regardless of employer size, if you see a provider out of network, there is a possibility neither your Group Plan nor Original Medicare will pay.
Sorting through this issue can be complicated. We are Medicare broker/consultants who can help you decide which option works for you. If Medicare is your primary coverage, we can help you investigate your options for Medicare Supplement or Medicare Advantage plans.Read More
Since the start of the Affordable Care Act, which was initiated in March 2012 and fully implemented in January of 2014, the number of uninsured in California has decreased. In 2013 the uninsured rates were 16%. By 2015, it dropped to 9%. This is due to the effect the health law has made specifically in terms of mandating guaranteed issue plans regardless of health and minimum essential benefits which closed many coverage gaps plans had pre-ACA.
However, there are many who do not have health insurance. One reason is the premium you have to pay for a plan. Another reason is the process for signing up can be intimidating.
There are two methods of applying for Individual and Family health insurance. One is to go directly to a health insurance plan through a health insurance broker or agent. The other is to get it through Covered California. The advantage of getting it through Covered California is, if you qualify based on income, you will get Premium Tax Credits to help offset some of the premiums you pay. An example of this is if you are a 25 year old earning $24,000 a year, you will get approximately $137.00/month in Premium Tax Credits. Covered California will send the Premium Tax Credits to any plan you choose. You will then pay the net amount after it is applied. As Covered California certified insurance agents, we can assist you in determining what Premium Tax Credit you qualify for and what plan meets your coverage.
There are serious consequences for not having insurance. If you become seriously ill or injured and have to go to the emergency room or get admitted to the hospital you can be tens of thousands or even hundreds of thousands of dollars out of pocket. Needless to say, this is a financial catastrophe for any individual of the family. Also, as of January 1, 2020, the state of California is imposing a penalty for individuals and families who do not have insurance. The penalties will be similar to the penalties the federal government imposed a year earlier.
The good news is that there will be the California State Tax Subsidy Program which will help consumers who previously have not qualified for Premium Tax Credits.
- Open Enrollment. This is a 3-month window typically starting in either mid-October or the first of November and ending on either January 15 or January 31.
- The earliest effective date for plans is Jan 1 if the application is completed before Dec 15 of the previous year.
- You can apply or change plans at this time
- Special Enrollment. This is the enrollment period outside of open enrollment.
- In order to enroll or change plans, you have to have a Qualifying Life Event. An example is losing group health insurance or Medi-Cal.
- Who can apply for health insurance through Covered California?
- Everyone who can demonstrate lawful presence can apply. There is an income criterion to qualify for Premium Tax Credits
- Who is eligible for Premium Tax Credits (APTC) and Cost Share Reduction?
- Any household whose income is between 138%-400% of the Federal Poverty Level (FPL) qualifies for APTC
- Any household whose income is between 138% and 266% of FPL qualifies for CSR
- What is the California State Subsidy Program?
- It is a program that will begin on Jan 1, 2020
- Any household whose income is between 401%-600% of FPL qualifies for this premium assistance
- Where can I apply?
- The only place to get APTC and CSR are with health insurance plans through Covered California. As Certified Covered California Agents, we can help you apply
- What is Cost Share Reduction?
- It only applies to Silver plans. A portion of your copays and deductible are paid for by Covered California with you paying the reduced amount.
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