WHEN I RETIRE, DON’T I GET HEALTH COVERAGE THROUGH THE WRITERS GUILD INDUSTRY HEALTH FUND? If you have 68 qualified quarters (for those retiring on or after January 1, 1997) when you retire and begin drawing your pension, you will be considered a Certified Retiree. The Health Fund will be your primary healthcare carrier from 60 until 65, at which time the federal health insurance Medicare program becomes available and is treated as your primary coverage – when this happens, the Health Fund moves into a secondary position. (There is no Certified Retiree coverage before age 60.)
HOW DOES A WRITER BECOME A CERTIFIED RETIREE? For every year you qualify for healthcare coverage you accrue four quarters toward your Certified Retiree status. Once you reach 68 qualified quarters (for those retiring on or after January 1, 1997), when you opt to take your pension you are considered a Certified Retiree and can receive health coverage beginning at age 60. (Note: Before 1988, there were different criteria for accruing points.
For more information about this, see the Health Fund Summary Plan Description (SPD)
Failing to enroll in Medicare in a timely manner costs you money – twice! Once when you have to pay medical costs that might have been covered if you had enrolled on-time and once again when you have to pay an increased monthly Medicare premium for enrolling late.
IF I WANT TO ENROLL IN MEDICARE PART A AND PART B WHEN I TURN 65, WHAT ARE THE TIME LIMITS FOR WHEN I HAVE TO APPLY? If you are not yet receiving Social Security benefits, you should apply three months before the month of your 65th birthday (Technically, you have until three months after the month of your 65th birthday to enroll, but if you enroll during the month in which you turn 65 or the three following months, the start date for your Medicare coverage will be delayed).
IF I’M A CERTIFIED RETIREE AND I’VE ALREADY GOT HEALTH COVERAGE, WHY DO I WANT TO ENROLL IN MEDICARE? Health Fund covers Certified Retirees as the primary carrier until they are 65, at which point Medicare becomes your primary health insurance carrier. This means that the Health Fund coordinates with Medicare so that you receive comparable benefits to when the Health Fund alone was providing coverage unless you are working and your employer provides health insurance – in which case Medicare will be the secondary carrier.
If you are a Certified Retiree and fail to enroll in Medicare Parts A and B, you will be fully liable for the medical costs that Medicare would otherwise have paid.
WHAT HAPPENS IF I DON’T ENROLL IN MEDICARE? If you are a Certified Retiree when you turn 65, Medicare becomes your primary health insurance carrier and the Health Fund moves into a secondary position. Even if you have not enrolled in Medicare, the Health Fund will pay its portion of the costs as if you are enrolled in both Part A and Part B, and will coordinate benefits as if you had received reimbursement for your medical expenses from Medicare. You will have to pay the difference between what the Health Fund pays and what Medicare would have paid if you had enrolled in Medicare.
As you will see below, that can be a lot of money:
Certified Retiree with and without Medicare Comparison Certified Retiree (enrolled in Medicare) Certified Retiree (not enrolled in Medicare) Multiple office visits (OOP not met) $120.00 $950.00
(In this example, failure to enroll in Medicare Part B cost the participant an extra $830)
Certified Retiree with and without Medicare Comparison Certified Retiree (enrolled in Medicare) Certified Retiree (not enrolled in Medicare) Single surgery (OOP not met) $164.51 $29,226.64
(In this example, failure to enroll in Medicare Part B cost the participant an extra $29,062.13)
Certified Retiree with and without Medicare Comparison Certified Retiree (enrolled in Medicare) Certified Retiree (not enrolled in Medicare) Single surgery (OOP met) $0.00 $2,632.42
(In this example, failure to enroll in Medicare Part B cost the participant an extra $2,632.42)
IS MEDICAL CARE MORE EXPENSIVE IF MEDICARE IS MY PRIMARY CARRIER? If, as a Certified Retiree, you enroll in Medicare when eligible, there typically is little – if any – difference in cost to the writer when Medicare is the primary carrier and the Health Fund is secondary.
Certified Retirees who are entitled to benefits under Medicare, whether or not they enroll, will be deemed to have enrolled for purposes of determining which plan is primary and what benefits
are payable by the Health Fund.
HOW DOES THE HEALTH FUND PAY BILLS WHEN I HAVE MEDICARE? The Health Fund coordinates your benefits with Medicare so that the combined medical payments of Medicare and the Health Fund are equal to – but not more than – what the Health Fund would have paid if Medicare were not
I AM WORKING AND I AM OVER 65. WHY ISN’T MEDICARE MY PRIMARY CARRIER? If you are working AND your employer provides you health coverage even though you are drawing your pension, then Medicare becomes the secondary carrier for as long as you’re actively employed and have health coverage.
When you continue to work and receive health coverage as a consequence of that employment, Medicare regards you differently than if you were retired and not working.
SO, IF I’M WORKING AFTER AGE 65 AND GETTING HEALTH INSURANCE COVERAGE AS A RESULT, DO I STILL NEED TO ENROLL IN MEDICARE WHEN I TURN 65? If you fail to enroll in Medicare Part A before the deadline (unless you qualify for a Special Enrollment Period), you will be liable for uncovered medical costs, and you will also pay a 10% penalty in additional premium payments for every 12- month period that you fail to enroll. You’ll have to pay the higher premium for twice the number of years you could have had Part A, but weren’t enrolled in the program.
It might be to your advantage to delay Part B (and Parts C and/or D) enrollment because your healthcare needs may be covered by your primary carrier as long as you or your spouse continues to receive health coverage from employment. If you want to ensure there is no possibility of error, you can enroll in Part A and/or B any time you are still covered by the group health plan or during your Special Enrollment Period (discussed in more detail later).
WHAT IF MEDICARE IS MY PRIMARY CARRIER AND THEN I GO BACK TO WORK? Once you are receiving health insurance from your employer, Medicare moves into a secondary position until your employer-provided coverage ends.
HOW DOES HAVING MEDICARE IN THE POSITION OF PRIMARY CARRIER AFFECT WHAT I HAVE TO PAY? There is usually little – if any difference – in cost to a writer when Medicare is in the primary position and the Health Fund is in second. (Note: If your doctor doesn’t accept Medicare, then the costs to you will be significantly higher. There is a detailed explanation of this in our on-line Medicare Users Guide in Section VI). There is usually little – if any – difference in cost to a writer when Medicare is in the primary position and the Health Fund is in second.
Note: If your doctor doesn’t accept Medicare, then the costs to you will be significantly higher. There is a detailed explanation of this here.
Below are two examples of typical costs when Medicare is the primary carrier and the Health Fund is in a secondary position (Active Earned means you are receiving health coverage as a result of employment):
Certified Retiree and Active Earbed Comparison Certified Retiree (enrolled in Medicare) Active Earned (no Medicare involvement) Provider’s Billed Amount $125,133.89 $125,133.89 Participant’s payment to the provider $1,100.00 $1,100.00
(In this example, there is no difference in cost to the participant)
Certified Retiree and Active Earbed Comparison Certified Retiree (enrolled in Medicare) Active Earned (no Medicare involvement) Provider’s Billed Amount $305.00 $305.00 Participant’s payment to the provider $38.30 $24.45
(In this example, the participant pays $13.85 more as a Certified Retiree)
HOW DOES MEDICARE WORK IF I GO BACK AND FORTH BETWEEN WORKING AND UNEMPLOYMENT? The simplest explanation is this: After age 65, when you are working and receiving health coverage from that employment, Medicare moves to the secondary position, and the coverage from employment is primary. When you are not receiving health insurance from employment, Medicare is the primary carrier.
While you are working and receiving health coverage from that employment, you may notify Social Security that you do not wish to pay Part B premiums. If you elect to go this route, you will not be penalized, but you must be very careful to renew Part B when you are no longer receiving health coverage from employment.
There is a Special Enrollment Period of eight months that begins the month after your employment ends or you are no longer receiving health insurance from your employer (whichever happens first) in which to enroll.
To avoid late enrollment penalties, make sure you apply and pay for Medicare Part B during your Special Enrollment Period. If you fail to make a payment during the allotted eight-month time frame, it will be the same as if you had never enrolled. You will have to wait until the following year during the General Enrollment Period to enroll, and you will incur a permanent 10% premium penalty for every year you delay.
In addition to the Medicare premium penalty and the loss of health coverage protection you are entitled to, if you fail to enroll in Medicare, Fund benefits will be reduced as if Medicare had paid its portion. (See APPENDIX A for a detailed example).
When a non-certified retiree transitions from employer-provided health coverage to full-time Medicare coverage, Medicare treats the time period(s) in which you apply for Medicare Part B differently depending upon how soon you apply. It works like this:
TIME PERIOD IN WHICH MEDICARE PART B IS REQUESTED MONTH COVERAGE BEGINS 1st THREE MONTHS WITHOUT EMPLOYER PROVIDED HEALTH COVERAGE Part B coverage starts the same month it is requested. 4th THROUGH 8th MONTH WITHOUT EMPLOYER PROVIDED HEALTH COVERAGE Part B coverage starts the month after the month requested
In addition to the Medicare premium penalty and the loss of health coverage protection you are entitled to, if you fail to enroll in Medicare, Health Fund benefits will be reduced as if Medicare had paid its portion. (See our on-line Medicare Users Guide Appendix A for examples)
WHAT IF MY DOCTOR DOESN’T TAKE MEDICARE? There are two ways a doctor may elect not to accept Medicare:
Non-Participating Providers are doctors who don’t routinely take Medicare assignment; they don’t accept Medicare’s discount system, nor will they provide the paperwork Medicare needs to pay on a claim.In order for the Health Fund to consider these claims you must submit a copy of the health provider’s opt-out letter to the Health Fund. Without this letter, the claim will be denied.
You will be responsible for the full cost of care you received. Since the provider doesn’t accept Medicare’s assignment, there would be no provider discount amount. The patient is responsible for the amount over Medicare’s allowance. You then have to contact the Health Fund and seek reimbursement for the portion the Health Fund would have paid if the provider had been paid by Medicare.
If the provider does not bill Medicare, you will have to bill Medicare. It is only after this Medicare bill has been submitted (by you) that the Health Fund will pay its portion.
Opt-Out Providers are doctors who formally opt-out of the Medicare system. If a doctor elects to go this route, they may not be accepted back into the Medicare system for 24 months.The Health Fund can help you with the complex paperwork required to get some healthcare cost reimbursement when dealing with a doctor who has formally opted out of Medicare
Medicare will not cover this provider’s services. If your doctor has opted out, he/she may have you enter into a private contract that requires the patient to pay for the services in full at the time they are provided.
The Health Fund does not honor private contracts and the Health Fund will process your claims as if Medicare is involved and estimate Medicare’s benefit.
If your doctor has made the decision to formally opt-out of Medicare you will be liable for higher costs. In this circumstance, it may be worth discussing the physician’s Medicare policy, or see if the doctor is willing to make some accommodations. If the doctor is unwilling to work with you, unfortunately a writer has to either accept higher costs or find a physician who does accept Medicare.Non-Participating and Opt-Out providers can make it difficult to ascertain what you should pay. If you need help with paperwork or managing administrative processes, please call the Health Fund at (818) 846-1015 and we will be glad to assist you.
No one likes the idea of having to look for a new medical professional, particularly if they have been working with the same medical provider for many years. If the doctor in question is an internist, you may want to elect to stay with the physician and pay the office visit costs. Blood tests, prescriptions and other medical procedures may well still be covered if they are provided by third parties who have not opted-out.
You will need to be especially careful if you choose to go this route should you be hospitalized, as any visits from your healthcare professional would be substantially more expensive for you than would be the case otherwise.
If you do decide you need a new healthcare provider, there is an enormous population of medical professionals to draw upon. (See APPENDIX E for more information)
If you live in Southern California, you may want to consider using The Industry Health Network. This is a PPO-type narrow network available only to entertainment industry professionals. It has very high quality services and very low copays.
Any time you have a question or concern, please reach out to us. We are committed to helping you to maximize the benefits to which you are entitled.