IF THE HEALTH FUND IS PRIMARY AND MEDICARE IS SECONDARY In this circumstance you have your traditional Fund coverage and Medicare will for the most part save you only a few dollars here and there. For all intents and purposes there is little or no difference in what you will pay for healthcare.
IF MEDICARE IS PRIMARY AND THE HEALTH FUND IS SECONDARY When Medicare is primary and Fund coverage is secondary, major medical issues will cost you pretty much the same – or even a little less than if you had the Health Fund coverage alone. (See APPENDIX B for some typical examples)
If you see a lot of doctors but rarely have medical issues which require hospitalization, then Medicare may end up costing you slightly more than if the Health Fund was your primary provider. (See APPENDIX C for details)
SPOUSES’ HEALTH PLANS AND HOW THEY MAY OR MAY NOT AFFECT YOUR COVERAGE
IF YOUR SPOUSE IS WORKING AND THE SPOUSE’S EMPLOYER IS PROVIDING HEALTH COVERAGE that covers you, then the spouse’s plan will become the primary carrier, Medicare will become the secondary carrier, and the Health Fund will be in third position (assuming you are a Certified Retiree).
IF YOUR SPOUSE IS WORKING AND YOU ARE ALSO WORKING, then your employer-provided coverage will be primary for your claims, your spouse’s coverage will be second, and Medicare will be third.
IF YOU AND YOUR SPOUSE ARE BOTH RETIRED AND GETTING RETIREE HEALTH COVERAGE FROM SEPARATE FUNDS, then Medicare would be your primary health coverage carrier, the Health Fund would be second, and your spouse’s would be third.
COB (COORDINATION OF BENEFITS)
One of the first questions writers ask is, “How does this all fit together and who do I turn to if there is a payment issue, Medicare or the Health Fund?” If there’s a problem, come to us, we’ll help you work through the process, and if necessary, we’ll assist you in dealing with Medicare.
ANNUAL DEDUCTIBLE AND OUT OF POCKET (OOP) COSTS The Health Fund has a $300 annual deductible, regardless of whether you are receiving services in-network or out of network. If you’re getting medical care from a provider in-network, the Health Fund covers 85% of the costs until you reach the $1,000 out-of-pocket annual maximum and then it covers 100% of costs.
If your medical care is coming from a doctor out-of-network, you still have an annual deductible of $300, and then the Health Fund pays 70% of costs until you reach the $2,500 out-of-pocket annual maximum after which the Health Fund cover 100% of costs.
IF YOUR SPOUSE IS WORKING AND RECEIVING HEALTH COVERAGE The Health Fund would be the secondary carrier if you and your spouse were both working and receiving health coverage.
If your spouse is working and you are a Certified Retiree, then your spouse’s plan would be primary, Medicare would be secondary, and the Health Fund would be third.
WHEN THE HEALTH FUND PLAN IS SECONDARY The Health Fund coordinates your benefits with Medicare so that the combined medical payments of Medicare and the Health Fund are equal to but not more than what the Health Fund would have paid if Medicare were not involved.
The same is true if your spouse’s plan is the primary carrier.
IF MEDICARE’S BENEFIT IS GREATER THAN THE HEALTH FUND The Health Fund pays nothing toward the claim in this circumstance. Once a writer has met the annual deductible and the OOP obligations, the writer usually won’t be paying any more than he/she would have if the Health Fund were the sole provider and in some cases he/she will actually pay less:
| Certified Retiree Medicare COB Calculation and Active Coverage Comparison | Certified Retiree | Active Coverage |
|---|---|---|
| Provider’s Billed Amount | $305.00 | $305.00 |
| Medicare/Fund’s Allowed Amount | $198.66 | $271.00 |
| Deductible met this claim (maximum of $300) | $10.00 | $10.00 |
| Applied to Out-of-Pocket (30% of Allowed Amount after deductible, max of $2,500) | $56.60 | $78.30 |
| Fund’s Normal Liability using Medicare’s Allowed Amount | $132.06 | $182.70 |
| Less: Medicare’s payment | $158.93 | $0.00 |
| Fund’s payment to the provider | $0.00 | $182.70 |
| Participant’s payment to the provider | $39.73 | $122.30 |
THINGS THE HEALTH FUND COVERS MEDICARE DOESN’T There is an additional benefit to Fund coverage in that the Health Fund covers services like acupuncture that Medicare does not, and often offers more generous numbers of appointments for things like physical therapy sessions. The Health Fund will coordinate with Medicare by taking into consideration Medicare’s allowable amount, and pay the difference up to the amount the Health Fund would normally pay.
OTHER CONSIDERATIONS If there is a hospital stay, the OOP mini- mums are generally easily met, but if you see doctor(s) several times a year, you will find that between Medicare and the Health Fund, your final out-of-pocket expenses may not exceed $1,300 (for 2015) for in-network providers and $2,800 (for 2015) for out-of-network providers. It is worth noting that most labs and anesthesiologists are out of network.
There is an additional expense incurred when Medicare is the primary health insurance carrier because there is a monthly premium for Medicare Part B, usually in the amount of $104.90 per month ($1,258.80 annually). See APPENDIX D for more details. See APPENDIX D for more details.
Having Medicare as your primary health care provider generally costs an additional $1,258.80 annually. To help offset some of this cost, when you turn 65, the Health Fund waives the dependent premium ($600 a year). Thus, if Medicare is your primary healthcare coverage provider, and you have dependents, you are generally looking at an additional $658.80 annually, rather than $1,258.80. If you don’t have a dependent(s), It’s worth noting that the Health Fund covers several potentially expensive services that Medicare does not: dental, vision, and prescription costs – as well as wellness care for both Earned Coverage participants as well as Certified Retirees.
MEDICARE ASSIGNMENT
DOES YOUR DOCTOR ACCEPT MEDICARE?
There are three possible answers to the question of whether or not a doctor accepts Medicare, and each of these has a vastly different consequence to you:
If you need help with paperwork or managing administrative processes, please call the Health Fund at (818) 846-1015 and we will be glad to assist you.
YES, MY DOCTOR DOES ACCEPT MEDICARE. This is the simplest outcome: The provider accepts Medicare’s approved amount and discounts the remaining amount. You have the normal annual deductible, OOP, COB, and you’re done.
NO, MY DOCTOR DOESN’T ACCEPT MEDICARE. There are two ways a doctor may elect not to accept Medicare:
Non-Participating Providers are doctors who don’t routinely take Medicare assignment; they don’t accept Medicare’s discount system, nor will they provide the paperwork Medicare needs to pay on a claim.
You will be responsible for the full cost of care you received. Since the provider doesn’t accept Medicare’s assignment, there would be no provider discount amount. The patient is responsible for the amount over Medicare’s allowance. You then have to contact the Health Fund and seek reimbursement for the portion the Health Fund would have paid if the provider had been paid by Medicare.
If the provider does not bill Medicare, you will have to bill Medicare. It is only after this Medicare bill has been submitted (by you) that the Health Fund will pay its portion.
Opt-Out Providers are doctors who formally opt-out of the Medicare system. If a doctor elects to go this route, they may not be accepted back into the Medicare system for 24 months. Medicare will not cover this provider’s services. If your doctor has opted out, he/she may have you enter into a private contract that requires the patient to pay for the services in full at the time they are provided. The Health Fund does not honor private contracts and the Health Fund will pro- cess your claims as if Medicare is involved and estimate Medicare’s benefit.
If your doctor has made the decision to formally opt-out of Medicare you will be liable for higher costs. In this circumstance, it may be worth discussing the physician’s Medicare policy, or see if the doctor is willing to make some accommodations. If the doctor is unwilling to work with you, unfortunately a writer has to either accept higher costs or find a physician who does accept Medicare.
No one likes the idea of having to look for a new medical professional, particularly if they have been working with the same medical provider for many years. If the doctor in question is an internist, you may want to elect to stay with the physician and pay the office visit costs. Blood tests, prescriptions and other medical procedures may well still be covered if they are provided by third parties who have not opted-out.
No one likes the idea of having to look for a new medical professional, particularly if they have been working with the same medical provider for many years. If the doctor in question is an internist, you may want to elect to stay with the physician and pay the office visit costs. Blood tests, prescriptions and other medical procedures may well still be fully covered.
You will need to be especially careful if you choose to go this route should you be hospitalized, as any visits from your healthcare professional would be substantially more expensive for you than would be the case otherwise.
If you do decide you need a new healthcare provider, there is an enormous population of medical professionals to draw upon. (See APPENDIX E for more information)
If you live in Southern California, you may want to consider using The Industry Health Network. This is a PPO-type narrow network available only to entertainment industry professionals. It has very high quality services and very low co- pays.
SUMMING UP
We hope you now better understand how Medicare works and how it affects your Fund coverage.
In the future, we will be holding seminars to help you learn more about Medicare. We will place a notice on the web site in advance of the event.
You can get more information at the PWGA web site: www.wgaplans.org or at Medicare’s own web site: www.medicare.gov.
Finally, please keep in mind, our staff is here to help you with any questions or concerns you might have: (818) 846-1015.