Medicare and Medi-Cal are big health insurance programs with lots of tiny pieces.
Medi-Cal is California’s state program that often provides health care coverage for children, some adults 18 to 21 years old, pregnant women and people with disabilities. It also covers people who make less than $13,000 a year. Medicare is the national health insurance program for people age 65 or older, and in some cases, for younger people with certain disabilities.
When the reforms called for by the Affordable Care Act go into effect January 2014, in addition to enrolling thousands of people who were previously uninsured, a number of Baby Boomers will also enroll in the plans. Health care plan management organizations anticipate only small changes to the Medicare and Medi-Cal programs themselves; the bigger task will be to explain the differences in the two similar-sounding programs and to help recipients understand the complex rules of each.
“I didn’t know anything about Medicare, Medi-Cal,” said Willie Posey a 73-year-old retired furniture mover. “I knew that when I became a certain age that Medicare kicked in.”
Posey is a patient at LifeLong Medical Care Over 60 Health Care Center, which has offices throughout Alameda County. He did not know his income allowed him to also receive coverage under Medi-Cal until the representatives at the health care center explained the benefits available to him.
Although he is happy to have coverage under both plans, he is unhappy with the program limitations that prevent him from making extra money—one of the complexities often ill-understood by recipients. He wants to work, but this could jeopardize his benefits.
“At some point in my past I got a little part time job and I made too much,” Posey said. “I was only to make $1,062 but I went over. It was like $1,800, which is very little money, but I messed up my Medi-Cal and that was a bad thing I’d done. Lord have mercy!”
Posey said he was scheduled to have surgery more than a year ago and had to put it off because he lost his Medi-Cal coverage. “I was feeling I needed more money,” Posey said. “My significant [other] and I would be able to go joy riding more and do some of the little fun things. Now, I have cleaned up my wreckage and I am back on [Medi-Cal].”
Cheryl White is a Medicare recipient and a patient with LifeLong Medical Care who goes to the Over 60 Health Center in Berkeley to see the doctor. She understands the difference between the two plans because she only qualifies for coverage under one. “I make just a little bit above the cut-off point,” White said.
Sitting in her wheelchair at the bus stop, she said she was happy to be able to get out on her own. But getting the wheelchair was hard work because only a fraction of the cost was covered under Medicare. “I was assessed to get a wheelchair, but I cannot afford the thousands of dollars, the twenty percent of Medicare that I have to pay for durable medical equipment,” White said.
In the end, White said, a friend was able to give her a used wheelchair. It’s 13 years old. If she didn’t have it, she would be housebound.
Posey and White both say one of the biggest challenges for recipients of these two programs is paying for prescription drugs. Posey is a diabetic and White has several chronic illnesses requiring daily medication.
“I have to take over twelve medicines,” White said. “Several of them are over $200. There’s a couple that are over $300. So once I hit the gap, I end up hitting that in March or April, then I have to pay all of that.”
White also receives assistance from the staff at the Over 60 Health Center with filing the papers required by patient assistance programs so she can receive the additional medication she needs. “I ran through my IRA paying for my medicine,” she said.
Marty Lynch, the executive director of LifeLong Medical Care, said that one of the difficulties patients experience is poor coordination of benefits. “It’s just two different systems that don’t work so well together,” Lynch said.
Several services related to Medicare and Medi-Cal have been cut since the budget crisis began in 2008. California Governor Jerry Brown almost totally eliminated adult day care programs for very disabled older people, including in-home support services that were funded under Medi-Cal. “We had to close one of our sites because of the cuts,” Lynch said. (You can read more coverage from Oakland North here.)
A few years ago adult dental care was also eliminated from the plan.
“I think we are going to see some improvements that will be a benefit to patients,” Lynch said. “There are a number of steps that will improve care over time as well as improving insurance coverage in 2014.”
Once of those steps will be the increased use of electronic record-keeping, making information more readily available for doctors, hospitals and home care workers. It should serve to prevent some mistakes and allow better coordination of medical treatments and medication distribution, Lynch said.
While the Over 60 Health Clinics see a large number of patients who have no insurance coverage, the California Department of Aging’s Health Insurance Counseling and Advocacy Program (HICAP) works with individuals who are or will soon be eligible for Medicare. “We are like consumer advocates,” said Janet Van Deusen, the program’s executive director for Alameda County.
The state and federally funded program helps Medicare recipients understand their coverage, their rights and their options for supplementing Medicare, Van Deusen said. Staffers sit down with each person and go over his or her medical plan, which is funded by the taxes people have contributed over time to the plan. Many calls received now are from the Baby Boomers who will soon turn 65 and who are seeking information about Medicare, she said.
This process can be overwhelming for people who have never had to think about it before, Van Deusen said, but plan recipients are already starting to see some positive modifications in the program. “The new reforms have helped,” Van Deusen said. “There have been some positive changes in terms of adding some preventive care benefits and improving the coverage gap for Medicare prescription drugs benefits, so there are fewer out-of-pocket costs for Medicare beneficiaries.”
People like Posey and White hope that January will bring even more changes that provide more coverage for their daily needs. “I am hoping that some of these problems will be taken care of when health care [reform] goes through,” White said. “I’m scraping by.”