health care guide 9_29

7272019 Health Care Guide 9_29

httpslidepdfcomreaderfullhealth-care-guide-929 125

A Guide to the Affordable Care Act A Brief outline of choices of health care with

emphasis on people with HIVAIDS

Erik WaltonThis information was updated on 9292013



2

Table of Contents

Introduction 3

Flow Chart 4

If you are employed and have health insurance 5

What Ryan White Will Still cover 5

If you are uninsured and make more than $15k 5

OA-HIPP 5

If you are Medi-Medi (MedicareMedi-Cal) 6

Cal ldquoMedi -Connectrdquo 6

Medicare Advantage Options 6 ldquoOpting Outrdquo ndash Keeping your Medicare 7

Assignment of Benefits if you keep your Medicare 8

MedicareMedi-Cal differences 9

Full Scope Medi-Cal (Income less than 15k a year) 10

HMO Choices for San Diego County 10

Veterans and the Affordable Care Act 11

In Conclusion 13

Important Phone Numbers and web sites 13

Source Material amp Affordable Care Act information Websites 14

Covered California FAQrsquos 16

San Diego Insurance Marketplace Contact Information 16

Definition of Terms 19

People With Medicare and the Health Insurance Marketplace FAQrsquos Handout from the

US Department of Health and Human Services 24



3

Introduction

Irsquove had a great deal of experience with health care issues I am 25+ years POZ and have been a Peerad vocate for over 5 years now Irsquom not an expert Irsquom just relaying information that I haveresearched and experienced dealing with insurance and benefits over the years This affects me asmuch as you so thatrsquos why Irsquove taken the time and effort to prepare this Having been through themaze of public programs over the years Irsquove learned how to problem solve many iss ues anddifficulties I had the good fortune of having two people who inspired me to become a peer advocatecounselor John Kehoe who was a Peer Advocate who helped me when I first came to San Diego In1997 and Debra Burl who was my case manager for many years and literally saved my life Iwatched learned took notes and most importantly I asked a lot of questions I vowed that I followin their footsteps and would pay it forward so here it goes-

This health care law isnrsquot the best that it could be but itrsquos a start I hope this information helps

alleviate some doubts and questions Knowledge is Power

(PS - if you have any comments or things you would like me to add or correct please e-mail meerikwaltonhotmailcom )

Note This is a dynamic document I have had to revise this at least ten times already since June whenI started compiling this information due to changes that have been implemented since then and areongoing hellip There are still many issues that need to be decided on and are in negotiation between the

Federal Government and the State of California hellip The Date on the front and on the flow chart will be the date of the last revision E-mail me forupdateshellip

copy Copyright 2013 Erik Walton



4

FLOW CHART OPTIONS FOR HIVAIDS HEALTH CARE UNDER THE AFFORDABLE CARE ACT 9292013





6

Important to note Make SURE your doctors and specialists are covered under the plan you chooseYou can ask them which ones they plan to join Enrollment period is October 1 2013 and endsJanuary 1 2014 It is important you enroll during this time

There are basically four different tiers of coverage

Bronze 60 coverage (you pay 40 of costs)

Silver 70 coverage (you pay 30)

Gold 80 coverage (you pay 20)

Platinum 90 coverage (you pay 10)

You also pay according to your age your county and income level

Yup itrsquos complicated (See Covered California FAQrsquos on page 16) Take your time and make sure youunderstand what yoursquore getting into Donrsquot be afraid to ask for help Contact an independentinsurance agent or someone you trust such as an insurance counselor with AARP or anotherknowledgeable organization to help explain it to youhellip (See resource numbers page 12) Itrsquosrecommended for people with HIV who qualify for OA-HIPP to get the platinum plan to keep theirout-of-pocket costs down The most they will pay for premiums is $1938 a monthhellip most premiumsshould be far below thathellip

For more information on your specific city and plans that are available there go towwwcoveredcacom or call them and they will walk you through a worksheet with your bestoptions They have on line counselors available to help you determine your best coverage optionsADAP will still take care of co-pays and costs of your HIV meds not covered by your insurance

Note to OA-PCIP enrollees Yes you will have to choose insurance through the Covered CaliforniaPlan by January 1 2014 Again the Office of AIDS will be offering assistance with premiums but anyother assistance is yet to be determined

If you are ldquoMedi-Medi rdquo or ldquoDual Eligiblerdquo You will be required to enroll in a Medi-CalHMO They are also going to ask (if you have no share of cost) to enroll in a program

called ldquoCal Medi Connectrdquo Enrollment start is expected to be April 1 2014The state of California is getting out of the ldquosingle -payerrdquo Medi -Cal theyrsquove done in the past Thereare five HMOrsquos to choose from in the county of San Diego which I will outline later on Medi-Connect plans are HMOrsquos basically a trial roll-out of a MedicareMedi-Cal merger in an effort to cutdown on redundancy and consolidate billings



7

HOWEVER Beneficiaries who have a Medicare Advantage plan will not be asked to join This

means they can continue to see the same Medicare doctors and providers they see today

If you are enrolled in a Medicare Advantage plan they will not ask you to enroll

though you may choose to join at any time if you qualify For others enrolled inMedi-Medi with no share of cost you also have the option of ldquoOpting outrdquo ( thisincludes those enrolled in the 250 working disabled program that have no share

of costhellip )

ldquoOpting outrdquo is when an eligible beneficiary chooses not to join a Cal Medi-Connect health plan andkeep his or her Medicare benefits separate and out of the Medi-Connect health plan Beneficiarieswho enroll in a Cal Medi-Connect health plan may ldquo opt out rdquo or change health plans at any time

Note Opting out applies only to Medicare benefits Beneficiaries must still get their Medi-Calbenefits through a health plan as described below

For people with both Medicare and Medi-Cal who do not enroll in a Cal Medi-Connect HealthPlan The state will require enrollment in a Medi-Cal plan for all Medi-Cal long-term services andsupports and any Medicare deductibles or costs and if you do not they will choose one for youFor dual eligible beneficiaries enrolling in a Medi-Cal health plan does not change your Medicarebenefits You can still go to your Medicare doctors hospitals and providers

Some Reasons to Opt Out

o Your doctor or specialists that you see are not enrolled in or choose not to enroll inone of the 4 HMOs

o You have special prescription(s) that are covered under your ldquoPart Drdquo prescrip tiondrug plan that are not covered under any other plan

o You wish to keep seeing all of your current doctors and specialists who takeMedicare and donrsquot want to make any changes right now

Some Reasons to Opt in There may be Doctors in the ne twork who yoursquod really prefer to be with but they donrsquot takeMediMedi -

They often have a wider range of other services such as vision and transportation services

They often have educational and support groups ie pain management smoking cessationetchellip



8

For Kaiser SubscribersIndividuals enrolled in a Kaiser plan will not receive notices regarding Cal MediConnect and will notbe passively enrolled into Cal MediConnect However individuals enrolled in Kaiser will still have to

enroll in a Medi-Cal managed care plan for their Medi-Cal benefit (It will probably be mandatory thatthey enroll in a Kaiser Medi-Cal HMO which to me is a no-brainer since theyrsquore probably going torequire you enroll in the same company but it hasnrsquot been specifically defined yet but probably willbehellip) If a beneficiary enrolled in Kaiser would like to enroll in Cal MediConnect they would have todis-enroll from Kaiser and choose a Cal MediConnect plan This exception applies to both Medicareand Medi-Cal Kaiser plans

Continuing to see your current providers and the Medi-Connect PlansAfter enrolling in a Cal Medi-Connect health plan beneficiaries may continue seeing their existing

Medicare doctors for up to six months and their Medi-Cal providers for up to 12 months even if theproviders do not join the health planrsquos network During this time the health plans may try to bringmany of these doctors into their networks to ensure people donrsquot have disr uptions in their careMost likely this will not happen Additionally Cal Medi-Connect enrollees may at any time changeplans or go back to original Medicare

What happens if I decide to stay in her Medicare Advantage plan but there is no

matching Medi-Cal plan

Normally individuals who are in Medicare Advantage cannot enroll in Medi-Cal managed care fortheir Medi-Cal benefit unless the Medi-Cal managed care plan is operated by the same company thatoperates their Medicare Advantage planThis is called a ldquomatchingrdquo plan Instead the beneficiary would remain in Medi -Cal This ldquomatchingrdquopolicy will not apply For example an individual who is enrolled in United Healthcare for MedicareAdvantage will still have to enroll in a Medi-Cal managed care plan despite the fact that UnitedHealthcare does not offer a Medi-Cal managed care plan (Me sounds really messed uphellip hopefully theyrsquoll fix that before

Aprilhellip Therersquos a lot of stuff thatrsquos still up in the air so stay tuned )

Should you decide to keep your current doctor and opt out Make SURE that they have accepted

something that Medicare calls ldquoassignmentrdquo here is the explanation taken from the Medicare Website httpwwwmedicaregovyour-medicare-costspart-a-costsassignmentcosts-and-assignmenthtml

Assignment means that your doctor provider or supplier agrees (or is required by law)to accept the Medicare-approved amount as full payment for covered services hellip



9

IMPORTANT If you choose to keep your Medicare make sure yourdoctor provider or supplier accepts assignment Otherwise you may geta bill

Most doctors providers and suppliers accept assignment but you should always check to makesure Participating providers have signed an agreement to accept assignment for all Medicare-covered services

What happens if your doctor provider or supplier accepts assignment

Your out-of-pocket costs may be less They agree to charge you only the Medicare deductible and coinsurance amount and usually wait

for Medicare to pay its share before asking you to pay your share They have to submit your claim directly to Medicare and cant charge you for submitting the claim Ask your Doctor If the Doctor doesnrsquot know ask to speak with his insurance person office

manager Many times the office will not bother to bill for the additional 20 of the balancebecause itrsquos a lot of work for very little reimbursement

Non-participating providers are ones that havent signed an agreement to accept assignment for allMedicare-covered services but they can still choose to accept assignment for individual servicesThese providers are called non-participating (You will most likely not encounter this situation but I

have presented it here in case you do run into ithellip)

If your doctor provider or supplier doesnrsquot accept assignment

You might have to pay the entire charge at the time of service Your doctor provider or supplier issupposed to submit a claim to Medicare for any Medicare-covered services they provide to you

They cant charge you for submitting a claim If they dont submit the Medicare claim once you askthem to call 1-800-MEDICARE

In some cases you might have to submit your own claim to Medicare using Form CMS-1490S to getpaid back

They can charge you more than the Medicare-approved amount but theres a limit calledthe limiting charge The provider can only charge you up to 15 over the amount that non-participating providers are paid Non-participating providers are paid 95 of the fee scheduleamount



10

The limiting charge applies only to certain Medicare-covered services and doesnt apply to somesupplies and durable medical equipment

Not sure if your doctor is covered by Medicare or one of the plans you are choosing

Ask The Doctor may be covered under your Medi- Cal plan even though yoursquove opted out to keepyour Medicare Doctors Donrsquot be afraid to ask questions Your Health depends on it

THE DIFFERENCE BETWEEN MEDICARE AND MEDI-CAL(Medicare pays 80 of the billing less deductibles and co-pays Medi-Cal is billed the other 20)

(note Denti- Cal dental benefits are returning May 1 2014hellip YAY)



11

If you make less than $ $15856 a year or 138 of the FPL (Federal Poverty Level)

You are eligible for full scope Medi-Cal and must choose one of these five listed HMOs Enrollment

starts October 1 2013 Coverage will not begin until January 1 2014

These are the four HM Orsquos that will be choices in San Diego Note only one Community Health Groupis a ldquonon -profitrdquohellip

Care 1st Health Plan o New Members 1-855-905-3825 (TTY 1-800-735-2929)

Community Health Group CommuniCare Advantage o New Members 1-800-224-7766 (TTY 1-800-735-2929)

Health Net o New Members 1-888-788-5395 (TTY 1-888-788-6383)

Molina Dual Options o New Members 1-855-665-4627 (TTY 1-800-479-3310 CRS 711)

Kaiser Permanente (Not Available under Medi-Connect) o New Members 1-877-258-8951 or TTY 711

If you are going to choose one of these I suggest you read reviews of them on line and ask otherpeople you know about them Most importantly ASK YOUR DOCTORThey are going to be the onewhorsquos going to be making referrals for services specialists etc They will give you the best advice

Make sure any ldquopromisesrdquo for services that these HMOrsquos make that seem too good to be true arenrsquotlimited in some way or involve an extra cost or catch Read the fine print or better yet ASK

I have been informed that people with HIVAIDS can dis-enroll from a Medi-Cal HMO and go back toregular Medi- Cal To do this you have to have your Doctor fill out what they call a ldquo MERrdquo orldquoMedical Exception Report rdquo I have also been informed that it will not be easy and you may have toappeal their decision The final decision will be made by the Department of Health Care Services(DHCS)rsquos Med-Cal Managed Care Division It is also recommended that you have an experiencedhealth care counselor guide you through this process

Remember that these are all (but one) are ldquofor profitrdquo companieshellip that means despite theintentions and regulations of the Affordable Care Act they are still worried about the bottom linehellip If you choose one of these keep that in the back of your mind Some of these I havenrsquot heard of before and others Irsquove heard good and bad Get as much information as you can to make the bestdecision possible (My personal experience has been that for example the dental plans really arenrsquot worth it and have REALLY high

deductibles But Gov Jerry Brown just signed a Bill re-instating Denti-Cal effective May 1 2014 and will require ALL plans to cover full dental services)



12

Veterans Health Care and the Affordable Care act

The health care law does not change VA health benefits or Vet eransrsquo out-of-pocket

costs Your TRICARE coverage makes you exempt from the Affordable Care Act

However you may supplement your care with other coverage

Three things you should know1 VA wants all Veterans to receive health care that improves their health and well-being2 If you are enrolled in VA health care you donrsquot need to take additional steps to meet the

health care law coverage standards The health care law does not change VA healthbenefits or Veteransrsquo out -of-pocket costs

3 If you are not enrolled in VA health care you can apply at any time Here is moreinformation I pulled from the US Dept of Veterans affairs website

Veterans Enrolled in VA Health CareThe good news is that Veterans enrolled in VA health care programs have health coverage thatmeets the new health care lawrsquos standard You do not have to take any additional steps to havehealth coverage

Veterans Not Enrolled in VA Health CareVeterans not currently enrolled in VA health care program can apply for enrollment at any time

Family MembersVA offers health care benefits for certain family members of Veterans through programs such as theCivilian Health and Medical Program of the Department of Veterans Affairs (CHAMPVA) and the SpinaBifida programYour family members who are not enrolled in a VA health care program should use the HealthCare marketplace to get coverage



13

Additional Health Care Law InformationWe understand you may have questions about the health care law and how it might affect you andyour family We compiled a list of Frequently Asked QuestionshttpwwwvagovhealthacaFAQasp to help you make informed decisions about your healthcare Let them know if you have questions regarding the health care law and your VA health care at1-877-222-VETS (8387)

Can I continue to use VA health care with other programs like private insurance orfederal health care programs

Yes You can continue to use VA for all your health care needs or complement your VA care with private health insurance or coverage by other federal health care programs including privateinsurance Medicare Medicaid and TRICARE

Canceling Your EnrollmenthellipA Word of Caution

If you choose to cancel your VA health care enrollment you may reapply for enrollment at anytime however acceptance for future VA health care enrollment will be based on eligibility factorsat the time of application which may result in a denial of enrollment



14

IN CONCLUSIONhelliphellip

The final decision for health care should be made between you and your health care practitioner

Period Donrsquot feel pushed or pressured by aggressive agents or salesmen who have an agenda andget a commission from the companies for signing people up Go on line and do research Take notesSeek out impartial advice Go to panel discussions Ask as many questions as you feel necessary If it rsquosnot clear to you ask them to explain it until you do If it doesnrsquot feel right donrsquot do ithellip Itrsquos your bodyand health OWN it Your life REALLY does depend on it

IMPORTANT PHONE NUMBERS

Being Alive San Diego Peer Advocacy

4070 Centre St San Diego CA 921036192911400

wwwbeingaliveorg

Health Insurance Counseling and Advocacy ProgramHICAP1-800-434-0222

httpwwwcahealthadvocatesorgHICAP

Disability Help Centerhttpwwwssdhelpcenterorg

1833 4 th Ave San Diego CA 921016192821761

Elder Law and Advocacy httpwwwseniorlaw-sdorgprogramshicapphp

Can answer questions about your Medicare andMedi-Cal coverage

5151 Murphy Canyon Road Suite 110San Diego CA 92123

(858) 565-8772

California Office of AIDShttpwwwcdphcagovprogramsAIDSPagesDefaul

taspx 1-916-449-5900

Covered California

1-800-300-1506wwwcoveredcacom

AARPwwwaarporg 1-888-687-2277

Medi-Cal wwwmedi-calgov

1-866-262-9881Medicare

1-800-633-4227 orwwwmedicaregov

Social Security Administration1-800-772-1213

wwwsocialsecuritygov

The Consumer Center for Health Educationand Advocacy -

httpwwwlassdorgCCHEA20broc20Ap222008pdf

619-744-0935

Veterans administrationhttpwwwvagov

1-877-222-VETS (8387)



15

Source Material amp Affordable Care Act information Websites

httpwwwnsclcorgindexphphealthaca

California State Insurance Exchange

AAHIVM Essential Health Benefits

Qualified Health Plans

Search Results opting out | Cal Duals

Californiarsquos Duals Demonstration ndash Cal MediConnect | Cal Duals

Frequently Asked Questions | Cal Duals

wwwsfhivorgwp-contentuploadsPlanning-considerations_providers_4-16-13pdf

Health Care Reform Transition | SFHIVORG

Task Force Releases Recommendations to Help San Franciscans Living with HIV Navigate Health Care Reform | SFHIVORG

wwwcdphcagovpubsformsfiscalrepDocumentsADAP May Revise FY2013-14 FINALpdf

wwwcdphcagovprogramsaidsDocumentsIntegratedPlanpdf

Search Results Cal MediConnect

California Health Insurance | Covered Californiatrade

Download and customize Health Reform Q amp A for Ryan White Program Clients HIV Health Reform

wwwhivhealthreformorgwp-contentuploads201307NC-Client-Brochure-all-statespdf

Health Insurance Counseling and Advocacy Program

Elder Law Advocacy - Programs - HICAP Home | AARP Health Law Answers

Resources for Consumers amp Providers HIV Health Reform

State Resources for ACA Implementation HIV Health Reform

66147244246~aidsconnhivhealthreformorgwp-contentuploads201303California-Modeling-Finalpdf

NASTAD Health Reform Watch - February 12 2013

Ryan White amp the Affordable Care Act What You Need to Know

HIV Care and the Affordable Care Act - TheBodyPROcom

What does Marketplace health insurance cover Essential Health Benefits | HealthCaregov

wwwhivhealthreformorgwp-contentuploads201309Assessment-Workbook-Final-eForm-Enabledpdf

Ryan White HIVAIDS Program Information and Resources in San Diego County

Veteransrsquo Health Today - Summer 2013



16

Affordable Care Act -- VA Affordable Care Act and You

ACA Frequently Asked Questions -- VA Affordable Care Act and You

Target Center | Supporting HIV care through education and innovation


wwwcoveredcacomnewsPDFsCC_Health_Plans_Booklet-rev1-8-6pdf

wwwnastadorgDocsPublicResource2007918_ADAP Glossary_Final_Sept_2007pdf

health-lawcomwp-contentuploads201305042213-MediConnect-Whitepaper-FINAL-For-DISTRIBUTIONpdf


No need to juggle health reform info One-stop info from NASTAD HIV Health Reform

Costs amp assignment | Medicaregov

Get Covered Calculator | Covered Californiatrade

Affordable Health I nsurance | Covered Californiatrade

httpwwwvagovhealthaca



17

Covered California FAQrsquos

Thanks to Arin McNeese

What is Covered California

Covered California will make it simple and affordable for you to purchase high-quality health insurance and access financialassistance to pay for coverage You can shop online over the phone or in person to find the right health care insuranceoption for you

Through Covered California both individuals and small businesses can compare different health insurance plans Individualscan learn if they qualify for federal financial assistance that can lower the cost of health insurance Individuals also will be

able to find out if they are el igible for health programs like Medi-Cal In addition employers with fewer than 25 full-timeworkers will be able to find out if they qualify for a small business tax credit that can help cover the cost of providingemployee health care

When can I purchase coverage through Covered California

Enrollment in health plans through Covered California will begin later this year and continue until March 31 2014 You mustpurchase health insurance during this open-enrollment period in order to obtain coverage in 2014 If you do not enroll duringthis period you will not be assured a health plan will cover you ndash either through Covered California or in the private marketIf you have a life-changing event such as the loss of a job death of a spouse or birth of a child you are eligible for specialenrollment within 60 days of the event The next open-enrollment period begins in October 2014 for coverage in 2015

What kind of health insurance will be offered through Covered California

Covered California will offer Qualified Health Plans that are the same high-quality health plans available on the privatemarket today These Qualified Health Plans are guaranteed to provide essential levels of coverage and consumer protectionsrequired by the Affordable Care Act These plans will be offered in categories based on the percentage of covered expensespaid by the health plan

The health plan choices offered by Covered California will be as good as you can get anywhere ndash even if you are not eligiblefor a subsidy Health insurance companies must offer the same products at an identified price whether they are offeredthrough Covered California or in the open market

In addition to these traditional health plans Covered California will offer what is called catastrophic coverage which helpsprotect a person from financial disaster in the event of a serious and expensive medical emergency Catastrophic coverage isnot designed for day-to-day medical expense such as doctor visits prescription medicines or even emergency room visits Itis designed to cover excessive medical bills that occur above the limit that you would be able to manage financially CoveredCalifornia will provide catastrophic coverage those up to age 30 or those individuals who can provide a certification that theyare without affordable coverage or are experiencing hardship



18

How will Covered California make it easier for me to compare different plans

There will be four basic levels of coverage Platinum Gold Silver and Bronze This ranking system will make it easy to

compare different health plans As the metal category increases in value so does the percent of medical expenses that ahealth plan will cover These expenses are usually incurred at the time of health care services ndash when you visit the doctor orthe emergency room for example The health plans that cover more of your medical expenses usually have a higher monthlypayment but you will pay less whenever you receive medical care

You can choose to pay a higher monthly cost so that when you need medical care you pay less Or you can choose to pay alower monthly cost so that when you need medical care you pay more You can choose the level of coverage that best meetsyour health needs and budget

What kind of help is available to help lower the cost of insurance

Starting in 2014 individuals seeking health coverage will be helped to afford coverage in three ways

1 Tax credits Tax credits are available to lower the cost of health coverage for individuals and families who meetcertain income requirements and do not have health insurance from an employer or a government program Whenyou enroll in a health plan through Covered California tax credits can be immediately applied to the insurancepremium which reduces the amount you pay each month

2 Cost-sharing subsidies Cost-sharing subsidies reduce the amount of out-of-pocket health care expenses anindividual or family has to pay These expenses might include the copayment for health care services or other costs

3 Medi-Cal assistance Starting in 2014 the State of California is planning to expand the Medicaid program (calledMedi-Cal in California) to cover people under age 65 including people with disabilities with income of less than$15000 for a single individual and $31180 for a family of four The coverage is free for those who qualify and partof the provisions of the Affordable Care Act

Am I eligible for tax credits

Tax credits are available for individuals and families who meet certain income requirements and do not have access toaffordable health insurance through their employer that also meets minimum coverage requirements

Eligibility for tax credits is based on a standard called the federal poverty level that looks at the family income and thenumber of people in the family The size of the tax credit is based on a sliding scale with those who make less money gettinga larger financial assistance to lower the cost of their insurance coverage Individuals and families who make between 138percent and 400 percent of the federal poverty level may be eligible for a tax credit This means that an individual making upto $44680 and a family of four earning up to $92200 may be eligible for a tax credit

There are some key facts about tax credits

Tax credits lower the cost of your premium Tax credits reduce the amount of the premium amount you will payfor insurance

Tax credits help low- and middle-income individuals and families Tax credits are available to individuals andfamilies who meet certain income requirements

Tax credits can be used when you enroll Tax credits can be applied to the cost of your health plan when you enroll ndash you do not need to wait until file a tax return at the end of the year



19

Tax credits are only available through Covered California You must enroll in a health plan through CoveredCalifornia if you want to use your tax credits

Tax credits are paid directly to your health plan These tax credits are paid by Covered California to your healthplan to keep your costs low

Tax credits will be adjusted at the end of the year based on your actual income At the end of the year the taxcredits may be adjusted if your income is different than you anticipated This means that you will want to notifyCovered California if your income changes

Small businesses with 25 or fewer full-time equivalent are also eligible for tax credits if they meet certain criteria

Do I have to buy health insurance

If you dont have health insurance you should Health insurance is an important way to make sure we have access to medicalcare when we need it Starting in January 2014 most people will be required to have health insurance or pay a penalty if theydont Coverage may include employer-provided insurance coverage someone buys on their own Medicare or Medi-Cal

The penalty phases in for three years and becomes increasingly more costly In 2014 the penalty will be 1 percent of annual

income or $95 whichever is greater By 2016 the penalty will be 25 percent of your annual income or $695 This means thatif you do not have coverage in 2014 you will be required to pay a penalty when you file your taxes at the end of the year

Some people do not have to pay a penalty including

People who would have to pay more than 8 percent of their income for health insurance

People with incomes below the threshold required for filing taxes (in 2012 $9750 for a single person and $27100for a married couple with two children)

People who qualify for religious exemptions

Undocumented immigrants

People who are incarcerated

Members of Native American tribesThere will be a penalty for people who are not covered and do not fall into one of these categories Businesses with 50 ormore full-time equivalent employees may be subject to a penalty beginning in 2014 if it does not offer health insurance toemployees (and their dependents)

So far the Health Care companies to choose from in the San Diego market place are AnthemBlue Cross ndash wwwanthemcomca

1 (866) 721 1387Blue Shield - www blueshieldca planscom

1 (877) 646 1825

Health Net ndash wwwhealthnetcom Individual amp Family Plans (IFP) -

Customer Service1-800-839-2172Sales 1-800-909-3447

Molina ndash wwwmolinahealthcarecom Main Number 1-562-435-3666

Toll Free 1-888-562-5442

Kaiser ndashkp kaiser org 1-800-539-0691

Sharp ndash wwwsharpcom 1-800-82-SHARP (1-800-827-4277)





21

Covered California The health Coverage Marketplace in California where uninsured persons can

buy insurance under the Affordable Care Act

Deductible - A fixed dollar amount during the benefit period - usually a year - that an insured

person pays before the insurer starts to make payments for covered medical services Plans mayhave both per individual and family deductibles Some plans may have separate deductibles forspecific services For example a plan may have a hospitalization deductible per admissionDeductibles may differ if services are received from an approved provider or if received fromproviders not on the approved list

Dual-Eligible ndash Individuals who are eligible for both Medicare and MedicaidMedi-Cal

Federal Poverty Level The set minimum amount of gross income that a family needs for food

clothing transportation shelter and other necessities In the United States this level is determined

by the Department of Health and Human Services FPL varies according to family size The number isadjusted for inflation and reported annually in the form of poverty guidelines Public assistanceprograms such as Medicaid in the US define eligibility income limits as some percentage of FPL

Formulary A list of prescription drugs both generic and brand name that are available through

your health plan Your health plan may only pay for medications that are on the formulary

Health Plan Network A large group of physicians hospitals and other health care providers that

have agreed to provide medical services to a health insurance plans members at discounted costs

HMO (Health Maintenance Organization) An organization that provides health coverage

with providers under contract A Health Maintenance Organization (HMO) differs from traditionalhealth insurance by the contracts it has with its providers These contracts allow for premiums to belower because the health providers has the advantage of having patients directed to them but thesecontracts also add additional restrictions to the HMOs members

Medicaid A joint federal and state program that helps low-income individuals or families pay for

the costs associated with long-term medical and custodial care provided they qualify Althoughlargely funded by the federal government Medicaid is run by the state where coverage may vary

Medi-Cal The California Medical Assistance Program (Medi-Cal or MediCal ) is the name of

the California Medicaid welfare program serving low-income families seniors persons withdisabilities children in foster care pregnant women and certain low-income adults It is jointlyadministered by the California Department of Health Care Services (DHCS) and the Centers for



22

Medicare and Medicaid Services (CMS) with many services implemented at the local level mainly bythe counties of California Under the Affordable Care Act it will be extended to all with incomes of $15k or less

Medicare Advantage plan (Also known as Medicare Part C) A Medicare Advantage Plan is

a type of Medicare health plan offered by a private company that contracts with Medicare to provideyou with all your Part A and Part B benefits Medicare Advantage Plans include Health MaintenanceOrganizations Preferred Provider Organizations Private Fee-for-Service Plans Special Needs Plansand Medicare Medical Savings Account Plans If youre enrolled in a Medicare Advantage PlanMedicare services are covered through the plan and arent paid for under Original Medicare MostMedicare Advantage Plans offer prescription drug coverage

Medicare Part A Medicare Part A covers services (like lab tests surgeries and doctor visits) and

supplies (like wheelchairs and walkers) considered necessary to treat a disease or condition In

general Part A covers Hospital care Skilled nursing facility care Nursing home care (as longas custodial care isnt the only care you need) Hospice and Home Health Care

Medicare Part B Part B covers Medically necessary services Services or supplies that are needed

to diagnose or treat your medical condition and that meet accepted standards of medical practiceand Preventive services Health care to prevent illness (like the flu) or detect it at an early stagewhen treatment is most likely to work best Part B covers things like Clinical research Ambulanceservices Durable medical equipment (DME) Mental health (Inpatient Outpatient and Partial

hospitalization) Getting a second opinion before surgery Limited outpatient prescription drugs

Medicare Part B Premium You pay a premium each month for Medicare Part B (Medical

Insurance) Most people will pay the standard premium amount However if your modified adjustedgross income as reported on your IRS tax return from 2 years ago is above a certain amount you maybe charged an Income Related Monthly Adjustment Amount (IRMAA) IRMAA is an extra chargeadded to your premium Most people pay the Part B premium of $10490 each month in 2013 If you

have Medi-Cal without a share of cost they will pay your Part B premium

Medicare Part C Also known as ldquoMedicare Advantagerdquo are plans offered by a private company

that contracts with Medicare to provide Part A and Part B benefits to people with Medicare whoenroll in the plan Medicare health plans include all Medicare Advantage Plans Medicare Cost PlansDemonstrationPilot Programs and Programs of All-inclusive Care for the Elderly (PACE) In all typesof Medicare Advantage Plans there is coverage for emergency and urgently needed care Medicare



23

Advantage Plans must cover all of the services that Original Medicare covers except hospice care Original Medicare covers hospice care even if youre in a Medicare Advantage PlanThe plan can choose not to cover the costs of services that arent medically necessary underMedicare Medicare Advantage Plans may offer extra coverage like vision hearing dental andor

health and wellness programs Most include Medicare prescription drug coverage (Part D) Inaddition to your Part B premium you usually pay a monthly premium for the Medicare AdvantagePlan Most people pay the Part B premium of $10490 each month in 2013 Most of the time it isdeducted from your Social Security Benefit

Medicare Part D Pays for Prescription Medications There are many Part D Plans Each Medicare

Prescription Drug Plan has its own list of covered drugs (called a formulary) Many Medicare drugplans place drugs into different tiers on their formularies Drugs in each tier have a different cost

A drug in a lower tier will generally cost you less than a drug in a higher tier In some cases if yourdrug is on a higher tier and your prescriber thinks you need that drug instead of a similar drug on alower tier you or your prescriber can ask your plan for an exception to get a lower copayment

Medi-Connect The state Medi-Cal program and the federal Medicare program are partnering to

launch a three-year demonstration to promote coordinated health care delivery to seniors andpeople with disabilities who are dually eligible for both of the public health insurance programsldquodual eligible beneficiariesrdquo The program will be called ldquoCal-MediConnect rdquo

It will be implemented no sooner than January 2014 in eight counties Alameda San Mateo SantaClara Los Angeles Orange San Diego Riverside and San Bernardino

The Cal MediConnect program aims to improve care coordination for dual eligible beneficiaries anddrive high quality care that helps people stay health and in their homes for as long as possibleAdditionally shifting services out of institutional settings and into the home and community will helpcreate a person-centered health care system that is also sustainable

Medi-Medi See ldquoDual ndash Eligiblerdquo

OA-HIPP Stands for ldquoOffice of AIDS Health Insurance Premium Payment rdquo OA-HIPP is a program

that pays the monthly health insurance premiums for eligible Californian residents with an HIVAIDSdiagnosis This program is available to individuals with health insurance who are at risk of losing it aswell as to individuals currently without health insurance who would like to purchase it



24

OA-PCIPSimilar to OA-HIPP but Paid for a program called ldquoPre -existing Condition Insurance Planrdquo

this program has been phased out in favor of the Health Care exchange

Obamacare See ldquoAffordable Care Actrdquo

Opt-Out In this context when a person decides not to enroll in a Cal MediConnect program

Share Of Cost in addition to covering individuals who receive cash assistance from thegovernment Medi-Cal offers health care coverage to individuals and families who have incomes toohigh to qualify for welfare but too low to cover health care costs Medi-Cal requires some of theserecipients to contribute to their health care by paying a share of the cost of the services they receiveOnce a recipients health care expenses reach a predetermined amount (the share of cost) Medi-Cal will pay for any additional covered expenses for that month Share of cost is an amount owed tothe health care provider not to the state

Single-Payer Single-payer health care is the financing of the costs of delivering universal healthcare for an entire population through a single insurance pool out of which costs are met There maybe many contributors to the single pool (insured persons employers government etc)

TRICARE TRI-CARE formerly known as the Civilian Health and Medical Program of the Uniformed

Services (CHAMPUS) is a health care program of the United States Department of Defense MilitaryHealth System





2

Table of Contents

Introduction 3

Flow Chart 4

If you are employed and have health insurance 5

What Ryan White Will Still cover 5

If you are uninsured and make more than $15k 5

OA-HIPP 5

If you are Medi-Medi (MedicareMedi-Cal) 6

Cal ldquoMedi -Connectrdquo 6

Medicare Advantage Options 6 ldquoOpting Outrdquo ndash Keeping your Medicare 7

Assignment of Benefits if you keep your Medicare 8

MedicareMedi-Cal differences 9

Full Scope Medi-Cal (Income less than 15k a year) 10

HMO Choices for San Diego County 10

Veterans and the Affordable Care Act 11

In Conclusion 13

Important Phone Numbers and web sites 13

Source Material amp Affordable Care Act information Websites 14

Covered California FAQrsquos 16

San Diego Insurance Marketplace Contact Information 16

Definition of Terms 19

People With Medicare and the Health Insurance Marketplace FAQrsquos Handout from the

US Department of Health and Human Services 24



3

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8














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(858) 565-8772


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Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















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19


















1 (877) 646 1825




Toll Free 1-888-562-5442







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Introduction










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13








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wwwbeingaliveorg








(858) 565-8772


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Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







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22

















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8














9
















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wwwbeingaliveorg








(858) 565-8772


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Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















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1 (877) 646 1825




Toll Free 1-888-562-5442







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22

















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of costhellip )













8














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10








11

















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wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















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24













7





of costhellip )













8














9
















10








11

















12













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















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8














9
















10








11

















12













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













9
















10








11

















12













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













10








11

















12













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













11

















12













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













12













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













13








14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













14







wwwbeingaliveorg








(858) 565-8772


taspx 1-916-449-5900

Covered California




1-866-262-9881Medicare






619-744-0935


1-877-222-VETS (8387)



15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













15
































16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













16
















17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













17















18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













18



















19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24













19


















1 (877) 646 1825




Toll Free 1-888-562-5442







21





















22

















23















24















21





















22

















23















24













22

















23















24













23















24













24









