Robert’s Story

Robert is a 38 year-old paraplegic. He’s been receiving a Social Security Disability Insurance (SSDI) benefit for eighteen months and is starting to think about his health care options. He’s currently paying for private coverage, which is expensive, and he knows he’ll be eligible for Medicare after he’s been on SSDI for two years.

Robert has about $15,000 in assets so he knows he’s not eligible for Medi-Cal or a Medicare Savings Program. This is unfortunate because a Medicare Savings Program would have helped him pay for his Medicare coverage once he got it. And having Medi-Cal and Medicare together would provide more comprehensive coverage than just having Medicare alone.

Four Parts of Medicare

Robert does some research and learns that there are four “parts” of Medicare. Medicare Part A would help pay for his medical expenses if he had to stay in the hospital; Part B would help pay for his medical expenses outside the hospital; and Part D would help pay for his prescription drugs. Part C, also known as “Medicare Advantage,” would be a way for him to receive the services covered under Parts A, B, and D through a private company.

Although he’s not currently working, Robert has worked in the past and paid Social Security and Medicare taxes. This means he would not have to pay a premium for Part A, which is good news. The Part A premium can be as high as $437 per month. He would, however, have to pay for Part B coverage. The premium for Part B is $135.50 per month in 2019. Had he qualified for a Medicare Savings Program, his Part B coverage might have been paid for by one of those programs. But because his assets are too high, he’ll have to pay the Part B premium on his own.

Prescription Drug Coverage

Robert takes several different medications, so he definitely needs Part D Prescription Drug Coverage. He will have to sign up for a Medicare drug plan with a private company to get coverage. Robert has read about Part D coverage so he understands the basic guidelines that Part D plans must follow. Under a typical plan, he’d have to pay a premium for his drug coverage and he’d also have a $415 annual deductible. After he’s spent the $415 deductible, the plan would pay for 75% of his drug costs until his total drug costs reached $3,820. After that, he would enter the donut hole, which means he would have to pay a lot more for his drugs, though the Affordable Care Act means that he’d get a 75% discount on his brand-name drugs and a 63% discount on his generics. After his total drug costs have reached $7,654, the donut hole would end and he would only have to pay a small amount to get additional prescription drugs. Robert takes 4 different medications and he knows they aren’t cheap. He is extremely concerned about the coverage he’d get under Part D.

A friend tells him that this is the minimum coverage that companies have to provide and that some companies may offer better Part D plans. He does some research and finds a few plans that are a little more affordable, but still not ideal given his medication needs. He starts adding up his expenses under Medicare and he becomes worried. He’d be spending at least $2,000 per year on his prescription drugs. He’d also have to pay the $135.50 Part B monthly premium, not to mention the deductibles and coinsurance he might have to pay for Part B services.

That’s when Robert gets serious about Medicare Part C, also known as Medicare Advantage. If he enrolls in a Medicare Advantage (Part C) plan, he might be able to access all the services he needs under the different parts of Medicare at a lower price. He calls the Health Insurance Counseling and Advocacy Program (HICAP) at 1-800-434-0222, and they help him find a plan that will cover the costs of his Medicare expenses at a cheaper rate than what he’d pay under Original Medicare.

While he’s researching his Medicare options, Robert learns of a special program called the Working Disabled Program. Under this program, Robert may be able to qualify for Medi-Cal when he starts working. He knows that with both Medicare and Medi-Cal coverage, he’ll pay less for his medical care and prescription drugs. Robert wants to go back to work part-time in the future. He makes a note to himself that when he starts working, he should go to his county Medi-Cal office to learn more about the Working Disabled Program.