Example

Robert’s Story

Robert is 38 years old and became paraplegic after a diving accident a couple of years ago. He’s been getting Social Security Disability Insurance (SSDI) benefits for the last 18 months and private health coverage through Covered California, because he gets too much in SSDI to qualify for Medi-Cal health coverage.

However, Robert knows that he gets Medicare soon, once he’s been on SSDI for two years, and he’s starting to plan for that. This is a big deal, because once his Medicare coverage starts, he wants to stop his expensive private insurance.

Comparing Original Medicare with Medicare Advantage

As Robert starts looking into Medicare, he realizes that he has to choose between Original Medicare or a Medicare Advantage plan. If he does nothing, he’s automatically signed up for Original Medicare Part A and Part B, but he isn’t sure that’s what he wants.

Robert gets online and learns that with Original Medicare, he can choose from more doctors and see specialists when he wants to. He calls up his current medical providers and they all confirm that they accept Original Medicare. He also learns that he doesn’t have to pay a monthly premium for Part A, but he has to pay $174.70 each month for Part B.

The Medicare Advantage plans he looks at limit him to choosing his doctors from specific networks and require him to see a primary care physician before seeing specialists. However, most of the plans he looks at have lower copayments than Original Medicare and an out-of-pocket maximum, meaning that beyond the premium, he never has to pay more than $8,850 in a year for medical care. Furthermore, Medicare Advantage seems a little simpler, since it’s one unified plan, instead of multiple parts. For some Medicare Advantage plans, he has to pay $174.70 per month, the same as with Original Medicare Part B, while for other plans he has to pay higher premiums. After doing some math, he figures that overall, most Medicare Advantage plans are a bit cheaper than Original Medicare.

After exploring the pros and cons of Original Medicare and Medicare Advantage, Robert decides to stick with Original Medicare, because it’s more like his current private health coverage, a PPO that lets him see specialists at various different medical facilities. Even if Original Medicare ends up costing him a little more, it’s worth it to him because he can see the same doctors he has been visiting ever since his accident.

Since he wants Original Medicare, Robert doesn’t have to worry about signing up: Original Medicare coverage starts automatically after he’s been getting SSDI for two years.

Prescription Drug Coverage

However, Robert has to sign up for a separate Part D prescription drug plan, because Original Medicare Parts A and B don’t cover prescriptions and, unlike Parts A and B, Part D coverage doesn’t start automatically.

Robert reads up on Part D and learns that all Part D plans are privately run, but they must follow some basic rules set by the government. Robert has to pay a monthly premium for his coverage, an annual deductible, and copayments or co-insurance for his medications.

Robert takes four different medications and he knows they aren’t cheap, so he starts to worry, until a friend tells him that some companies may offer better Part D plans for Robert’s needs. Robert checks the Medicare Plan Finder and finds a few Part D plans that sound good to him. He chooses one that isn’t too expensive and that covers the prescription drugs he needs.

Learning about WDP

Robert enrolls in Part D and is happy with his overall Medicare coverage, because it is pretty comprehensive and costs less than his old private insurance. Even so, he wishes it were cheaper. After a few months, he calls up the Health Insurance Counseling & Advocacy Program (HICAP) at 1-800-434-0222 to see if there’s any way for him to save some money.

They tell him that if he also qualifies for Medi-Cal health coverage or for a Medicare Savings Program, his total medical expenses go down. However, Robert knows he doesn’t qualify for those because his SSDI payments are too high. That’s when the HICAP counselor tells him about a special program called Medi-Cal's Working Disabled Program.

Robert qualifies for WDP if he starts working, because WDP has a higher income limit than standard Medi-Cal. And, it even pays his Medicare Part B premium and some of his Medicare co-insurance and deductibles!

Robert wants to go back to work part-time in the future, so he makes a note to himself that when he starts working, he’ll call his county social services agency about it.