Appendix A
Example 1
Multiple Claims – WGIHF’s allowed amount is Greater than Medicare (deductible met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Signed Up Vs. Not Signed Up with Medicare | WGIHF is Secondary – Medicare Estimate 80% | |
| Certified Retiree (≥ 65) Signed with Medicare |
Certified Retiree (≥ 65) Not Signed with Medicare |
||
| Provider’s Billed Amount | $1,500.00 | $1,500.00 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $800.00 | $1,000.00 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Applied to Out-of-Pocket (15% of Medicare’s Allowed Amount, maximum of $1,000) | $120.00 | $150.00 | Applied to Out-of-Pocket (15% of Fund’s Allowed Amount, maximum of $1,000) |
| Fund’s Normal Liability using Medicare’s Allowed Amount (allowed amount less OOP) | $680.00 | $850.00 | Fund’s Normal Liability using Fund’s Allowed Amount (allowed amount less OOP) |
| Less: Medicare’s payment | $640.00 | $800.00 | Less: Medicare Estimated Payment (80% of Fund’s Allowed Amount) |
| Fund’s payment to the provider | $40.00 | $50.00 | Fund’s payment to the provider |
| Participant’s payment to the provider | $120.00 | $950.00 | Participant’s payment to the provider (includes Medicare estimated 80% of Fund’s Allowed Amount) |
In this example, the writer’s failure to apply for Medicare cost the writer an extra $830.
Example 2
Single Claim – WGIHF’s Allowed Amount is Greater than Medicare (deductible met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Signed Up Vs. Not Signed Up with Medicare | WGIHF is Secondary – Medicare Estimate 80% | |
| Certified Retiree (≥ 65) Signed with Medicare |
Certified Retiree (≥ 65) Not Signed with Medicare |
||
| Provider’s Billed Amount | $76,593.50 | $76,593.50 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $1,096.70 | $35,283.30 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Applied to Out-of-Pocket (15% of Medicare’s Allowed Amount, maximum of $1,000) | $164.51 | $1,000.00 | Applied to Out-of-Pocket (15% of Fund’s Allowed Amount, maximum of $1,000) |
| Fund’s Normal Liability using Medicare’s Allowed Amount (allowed amount less OOP) | $932.20 | $34,283.30 | Fund’s Normal Liability using Fund’s Allowed Amount (allowed amount less OOP) |
| Less: Medicare’s payment | $873.80 | $28,226.64 | Less: Medicare Estimated Payment (80% of Fund’s Allowed Amount) |
| Fund’s payment to the provider | $58.40 | $6,056.66 | Fund’s payment to the provider |
| Participant’s payment to the provider | $164.51 | $29,226.64 | Participant’s payment to the provider (includes Medicare estimated 80% of Fund’s Allowed Amount) |
In this example, the writer’s failure to apply for Medicare cost the writer an additional $29,062.14.
Example 3
Single Claim (deductible and OOP met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Signed Up Vs. Not Signed Up with Medicare | WGIHF is Secondary – Medicare Estimate 80% | |
| Certified Retiree (≥ 65) Signed with Medicare |
Certified Retiree (≥ 65) Not Signed with Medicare |
||
| Provider’s Billed Amount | $7,329.30 | $7,329.30 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $1,729.69 | $3,290.53 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Applied to Out-of-Pocket ($1,000 OOP met) | $0.00 | $0.00 | Applied to Out-of-Pocket ($1,000 OOP met) |
| Fund’s Normal Liability using Medicare’s Allowed Amount (allowed amount less OOP) | $1,729.69 | $3,290.53 | Fund’s Normal Liability using Fund’s Allowed Amount (allowed amount less OOP) |
| Less: Medicare’s payment | $1,378.13 | $2,632.42 | Less: Medicare Estimated Payment (80% of Fund’s Allowed Amount) |
| Fund’s payment to the provider | $351.56 | $658.11 | Fund’s payment to the provider |
| Participant’s payment to the provider | $0.00 | $2,632.42 | Participant’s payment to the provider (includes Medicare estimated 80% of Fund’s Allowed Amount) |
In this example, the writer’s failure to apply for Medicare cost the writer an additional $2,632.42.
Appendix B
Example 1
Hospital Claim – 20-day admission, PPO Provider (deductible met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Active Earned Vs Certified Retiree | Writers’ Guild-Industry Health Fund (WGIHF) is Primary No COB |
|
| Certified Retiree Participant ≥ 65 Years of Age |
Active Earned Participant ≤ 64 Years of Age |
||
| Provider’s Billed Amount | $125,133.89 | $125,133.89 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $9,829.65 | $115,304.24 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Patient’s $100 copay per admission | $100.00 | $100.00 | Patient’s $100 copay per admission |
| Applied to Out-of-Pocket (15% of Medicare’s Allowed Amount, maximum of $1,000) | $1,000.00 | $1,000.00 | Applied to Out-of-Pocket (15% of Fund’s Allowed Amount, maximum of $1,000) |
| Fund’s Normal Liability using Medicare’s Allowed Amount (allowed amount less copay and OOP) | $8,729.65 | $114,204.24 | Fund’s Normal Liability using Fund’s Allowed Amount (allowed amount less copay and OOP) |
| Less: Medicare’s payment (Medicare’s Allowed Amount less 1st 60 days patient coinsurance of $1,184) | $8,645.65 | N/A | |
| Fund’s payment to the provider | $84.00 | $114,204.24 | Fund’s payment to the provider |
| Participant’s payment to the provider (copay and OOP) | $1,100.00 | $1,100.00 | Participant’s payment to the provider (copay and OOP) |
In this example, there would have been no difference in cost to the writer when Medicare is the primary healthcare provider.
Note: For Medicare claims, the Fund allows Medicare’s allowance over Anthem Blue Cross
Example 2
Annual claims profile (includes Inpatient Hospital Services, deductible and OOP met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Active Earned Vs Certified Retiree | Writers’ Guild-Industry Health Fund (WGIHF) is Primary No COB |
|
| Certified Retiree Participant ≥ 65 Years of Age |
Active Earned Participant ≤ 64 Years of Age |
||
| Provider’s Billed Amount | $125,133.89 | $125,133.89 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $9,829.65 | $115,304.24 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Patient’s $100 copay per admission | $100.00 | $100.00 | Patient’s $100 copay per admission |
| Applied to Out-of-Pocket ($1,000 OOP met) | $0.00 | $0.00 | Applied to Out-of-Pocket ($1,000 OOP met) |
| Fund’s Normal Liability using Medicare’s Allowed Amount | $9,729.65 | $115,204.24 | Fund’s Normal Liability using Fund’s Allowed Amount (allowed amount less copay and OOP) |
| Less: Medicare’s payment (Medicare’s Allowed Amount less 1st 60 days patient coinsurance of $1,184) | $8,645.65 | N/A | |
| Fund’s payment to the provider | $1,084.00 | $115,404.24 | Fund’s payment to the provider |
| Participant’s payment to the provider | $100.00 | $100.00 | Participant’s payment to the provider (copay) |
In this example, there is no cost difference between Medicare and WGA coverage.
Note: For Medicare claims, the Fund allows Medicare’s allowance over Anthem Blue Cross
Example 3
Physician Services only – PPO Provider (deductible and OOP not met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Active Earned Vs Certified Retiree | Writers’ Guild-Industry Health Fund (WGIHF) is Primary No COB |
|
| Certified Retiree Participant ≥ 65 Years of Age |
Active Earned Participant ≤ 64 Years of Age |
||
| Provider’s Billed Amount | $305.00 | $305.00 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $198.66 | $106.34 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Deductible met this claim (maximum of $300) | $10.00 | $10.00 | Deductible met this claim (maximum of $300) |
| Applied to Out-of-Pocket (15% of Medicare’s Allowed Amount, maximum of $1,000) | $28.30 | $14.45 | Applied to Out-of-Pocket (15% of Medicare’s Allowed Amount, maximum of $1,000) |
| Fund’s Normal Liability using Medicare’s Allowed Amount | $160.36 | $81.89 | Fund’s Normal Liability using Fund’s Allowed Amount (allowed amount less copay and OOP) |
| Less: Medicare’s payment | $158.93 | N/A | |
| Fund’s payment to the provider | $1.43 | $81.89 | Fund’s payment to the provider |
| Participant’s payment to the provider | $38.30 | $24.45 | Participant’s payment to the provider |
In this example, the writer pays $13.85 more because Medicare is the primary provider than would have been the case if the WGA was the primary provider.
Note: For Medicare claims, the Fund allows Medicare’s allowance over Anthem Blue Cross (Medicare’s allowance greater than the Fund on the above example)
Example 4
Physician Services, PPO Provider (deductible & OOP Met)
| Medicare is Primary, WGIHF is Secondary – COB | Comparison of Participant Active Earned Vs Certified Retiree | Writers’ Guild-Industry Health Fund (WGIHF) is Primary No COB |
|
| Certified Retiree Participant ≥ 65 Years of Age |
Active Earned Participant ≤ 64 Years of Age |
||
| Provider’s Billed Amount | $305.00 | $305.00 | Provider’s Billed Amount |
| Medicare’s Allowed Amount | $198.66 | $106.34 | Fund’s Allowed Amount (based on Blue Cross contract) |
| Applied to Out-of-Pocket ($1,000 OOP met) | $0.00 | $0.00 | Applied to Out-of-Pocket ($1,000 OOP met) |
| Fund’s Normal Liability using Medicare’s Allowed Amount | $198.66 | $106.34 | Fund’s Normal Liability using Fund’s Allowed Amount |
| Less Medicare’s payment | $158.93 | N/A | |
| Fund’s payment to the provider | $39.73 | $106.34 | Fund’s payment to the provider |
| Participant’s payment to the provider | $0.00 | $0.00 | Participant’s payment to the provider |
In this example there is no difference between the cost to the writer whether the WGA is the primary provider or Medicare is in the first position.
Note: For Medicare claims, the Fund allows Medicare’s allowance over Anthem Blue Cross (Medicare’s allowance greater than the Fund on the above example)
Appendix C
WGA primary vs Medicare primary – cost to writer
Earned versus Retiree Coverage
Comparison of Premiums and COB Rules
| Health Coverage – Premium and COB Earned Coverage – No Medicare |
Health Coverage – Premium and COB Certified Retiree – Medicare Coverage |
| Premium: Individual premium: $ 0.00 Dependent Premium: $ 150 per quarter ($600 annually) Medicare Government Tax withholding: 2.9% of annual salary. 1.45% is paid by the employer and 1.45% is paid by the writer. All 2.9% is paid by the writer if there is a loan out company. |
Premium: WGA Individual premium: $ 0.00 WGA Dependent Premium: $ 150.00 per quarter (if age 65 or older, and on retiree coverage, the premium is waived) Medicare Part B Premium: $ 104.90 per month ($ 1258.80 annually) |
| COB Rule:
Usually, the plan covering someone as a participant based on employment is the primary plan and the plan covering someone as a dependent is the secondary plan.For dependent children covered under more than one plan – the birthday rule is applied. The plan of the parent whose birthday is earliest (month & day) in the year is the primary plan. If both parents have the same birthday, the primary plan is the one that has covered the parent longer. Please refer to the SPD for “Other COB Rules”. The Plan remains the primary coverage over Medicare if the participant is age 65 and over. |
COB Rule:
Medicare coverage will be the primary plan when the Certified Retiree turns age 65. If the Certified Retiree has coverage through another plan based on employment or covered as a dependent, the standard coordination of benefits determination for the secondary or tertiary will be made. See the SPD for the COB determination rules. |
| Medicare COB Approach: None – The Plan is the primary coverage and Medicare is secondary. |
Medicare COB Approach:
Carve Out or non‐duplication approach – Under this method, when the Health Fund is the secondary plan, the primary plan’s benefit is subtracted from the Health Fund’s normal benefit, and the difference, if any, is paid on the claim. If the primary plan’s benefit is greater than or equal to the Health Fund’s benefit on a claim, nothing is paid by the Health Fund. If the primary plan’s benefit is less than the Health Fund’s benefit, the difference between the two benefits is paid. With this method, the plan participant continues to be responsible for normal out- of-pocket expenses like deductibles and coinsurance. (see attached examples) |
Earned versus Retiree Coverage
Comparison of Benefits
| Health Coverage Earned Coverage – No Medicare |
Health Coverage Certified Retiree – Medicare Coverage |
| Hospital Coverage – WGA Coverage
– Inpatient Care in hospital Subject to the Plan’s hospital $100 copay, then the Plan’s Plan’s $300 deductible, payable at 85% INN or 70% OON until the out-of-pocket maximum is met (($1000 INN or $2500 OON), then payable at 100%, no lifetime maximum – Hospice care services Subject to the Plan’s $300 deductible, payable at 85% INN or 70% OON until the out-of-pocket maximum is met (($1000 INN or $2500 OON), then payable at 100%, no lifetime maximum |
Hospital Coverage – Medicare Part A
– Inpatient Care in hospital The patient pays $5 per outpatient prescription for pain and symptom management – Home health care services – 100% if medically necessary The patient pays 20% of the Medicare approved amount for durable medical equipment. |
| All other services
– Physician Services Subject to the Plan’s $300 deductible, payable at 85% INN or 70% OON until the out-of-pocket maximum is met (($1000 INN or $2500 OON), then payable at 100%, no lifetime maximum |
All other services – Medicare Part B
– Physician Services Subject to Medicare’s Part B deductible of $147, then payable at 80%. No out-of-pocket maximum. |
Appendix D
MEDICARE PART B COSTS
| Beneficiaries who file an individual tax return with income: | Beneficiaries who file a joint tax return with income: | Part B income-related monthly adjustment amount | Total monthly Part B premium amount |
| Less than or equal to $85,000 | Less than or equal to $170,000 | $0.00 | $104.90 |
| Greater than $85,000 and less than or equal to $107,000 | Greater than $170,000 and less than or equal to $214,000 | $42.00 | $146.90 |
| Greater than $107,000 and less than or equal to $160,000 | Greater than $214,000 and less than or equal to $320,000 | $104.90 | $209.80 |
| Greater than $160,000 and less than or equal to $214,000 | Greater than $320,000 and less than or equal to $428,000 | $167.80 | $272.70 |
| Greater than $214,000 | Greater than $428,000 | $230.80 | $335.70 |
Monthly premium rates to be paid by beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:
| Beneficiaries who are married and lived with their spouse at any time during the year, but file a separate tax return from their spouse: | Part B income-related monthly adjustment amount | Total monthly Part B premium amount |
| Less than or equal to $85,000 | $0.00 | $104.90 |
| Greater than $85,000 and less than or equal to $129,000 | $167.80 | $272.70 |
| Greater than $129,000 | $230.80 | $335.70 |
* All income levels are based on adjusted gross income
Appendix E
Medicare Providers Available in the Top Participant Geographic areas
| Zip Code | # of Providers with 25 miles (that accept Medicare Assignment) Specialty & Count | # of Providers with 25 Miles (that accept Medicare Assignment) Specialty & Count | # of providers within 25 miles (that accept Medicare Assignment) Specialty & Count | Number of Opt. Out Providers |
| Family Practice, General Medicine, Geriatrics, Internal Medicine | Hematology/Oncology | Cardiology | ||
| 90025 Los Angeles |
4,741 | 62 | 531 | 615 |
| 94112 San Francisco |
2,503 | 66 | 190 | 2658 |
| 10013 New York |
8,250 | 494 | 1,435 | 3286 |
Note: In-network Medicare Provider counts obtained from www.medicare.gov and Number of Opted Out Medicare Providers count was obtained from a Healthcare Payer.