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Making sense of Covered California and Medicare during open enrollment

It’s that time of year when we all have to start thinking about health insurance plans and options.

Not only do I need to figure out if my current plan will be offered again next year, and with what changes, but my husband is over 65, so I also have to research the latest Medicare plans as well.

As a columnist, research is my thing, but this insurance stuff makes my head spin.

Like it or not it’s time to start researching as open enrollment begins. Covered California open enrollment is Nov. 1 to Jan. 31, and Medicare’s is Oct. 15 to Dec. 7.

At healthcare.gov, there’s information about the various open enrollments, including for a Special Enrollment Period, due to a life event like losing other coverage, getting married or having a baby, as well as Medicaid or the Children’s Health Insurance Program (CHIP).

The government site also provides tips regarding the Health Insurance Marketplace and what’s required to be eligible to use these programs.

Making the right insurance choices can be confusing.

So I asked my pal Dr. Michael Brant-Zawadzki, FACR senior physician executive at Hoag Hospital, for some thoughts on how to maneuver through this medical insurance muddle.

Hoag is part of a 50, non-profit hospital system, the second largest west of the Mississippi, so I thought he’d have some good advice, and he did.

Brant-Zawadzki agrees that “Uncertainty about healthcare abounds, and it clouds our choices.”

He says it’s important to look at options, as it can come down to a tradeoff: choice versus cost.

Even with workplace health plans, this is the case as, “as employers increasingly select health plans that package hospitals and clinicians in a ‘narrow’ network,” hoping to spend less while “maintaining quality and patient satisfaction.”

I asked the good doctor about Medicare, as information is showing up in the mail, and from what I can see, it’s a bit confusing.

Brant-Zawadzki explained Medicare has two options.

“Selecting the traditional Medicare provides full choice of physicians and facilities, but entails out-of-pocket co-pays, and many buy supplemental insurance to cover the costs that Medicare does not cover,” he says.

The other choice, Medicare Advantage, is marketed to seniors by insurance companies and large health plans like Kaiser.

He says this is “attractive because it promises low or no out-of-pocket costs for doctors, hospitalization and drugs.”

But those choosing this option should be aware that Medicare Advantage plans offer members a network of physicians and facilities that they must use, according to the plan guidelines.

“Medicare Advantage plans typically require access for all care through an assigned primary care physician, who directs the care plan, including which tests and specialists the member will need,” says Brant-Zawadzki.

He explained these managed plans have contracted specialists, and sites of service, so patients’ choices of specialists is limited.

An unexpected emergency could find a patient here in a hospital not in their plan, resulting in transfer to a hospital within their plan.

“Likewise, an on-call specialist seeing that ER patient may not be on the plan, and may bill separately for professional services,” says Brant-Zawadzki.

“This scenario causes confusion and frustration, as well as unexpected bills for the patient, not to mention the disruption in the continuum of care,” he says.

Brant-Zawadzki says if Medicare Advantage is your preference, it’s a good idea to choose a plan that bundles the hospital, its facilities and the specialists you trust.

“Just because your favorite hospital is ‘in network’ on your plan does not mean that that hospital’s out-patient lab, imaging, colonoscopy or even ambulatory surgery facilities are also in your plan,” says Brant-Zawadzki.

Ask your primary care physician what contractual obligations he or she has within the plan you’ve chosen and what facilities and specialists to which you’d likely be directed.

“You may find yourself in a facility operated by an unfamiliar entity with an unknown diagnostician” Brant-Zawadzki says.

Medicare and Medicare Advantage plans can be confusing.

Patients should access all care from the hospital network of their choice and ensure that the plan they select gives them access to not only inpatient hospital care, but all of the additional services, such as imaging, physical therapy and other outpatient services.

Cover your bases, as you research health insurance choices.

Speak to an independent insurance broker.

And you might want to attend Hoag Hospital’s free seminars about the basics of Medicare, Medicare benefits, Medicare Supplemental Insurance Plans, Medicare Advantage HMO and PPO plans and Medicare Part D prescription drug coverage.

Classes begin in September and run through November at all three campuses in Newport, Irvine and Huntington Beach.

Reservations are a must and to find the location and times in your area visit hoagmedicalgroup.com/for-patients/classes/

BARBARA VENEZIA lives in Newport Beach. She can be reached at bvontv1@gmail.com.

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