Q&A: Medicare Advantage questions

Dear Liz: You posted a letter against Medicare Advantage plans. The letter suggested that you had to go to their doctors, which is false. You can go out of network with a higher deductible. I will also tell you that most of those same doctors accept your in-network deductible. I do this all the time when I’m at my summer home.

Answer:
As mentioned earlier, Medicare Advantage plans are offered by private insurers as an alternative to traditional Medicare. The plans can differ in what they cover and how.

For example, if your Medicare Advantage plan is a preferred provider organization, you may indeed have some coverage if you use a medical provider outside the plan’s network. If the Medicare Advantage plan is a health maintenance organization, the plan may not cover out-of-network care except in an emergency. HMOs also may require you to get a referral to see a specialist.

Contrast that with traditional Medicare, which allows you to see any medical provider that accepts Medicare (which is most of them). One of the downsides to traditional Medicare is the co-insurance, including deductibles and copayments. However, you can purchase a supplemental, or Medigap, policy from a private insurer to cover those. There are a number of Medigap plans, but what they cover is standardized.

Medicare Advantage plans often pay for things that Medicare does not, such as hearing, eye care and dental. Many people who sign up for Medicare Advantage are, like you, pleased with their coverage. Others are not, though. Read on:

Dear Liz: Regarding the pros and cons of traditional Medicare versus Medicare Advantage options, I want to share a personal horror story about my parents. Both are now deceased, and I went through hell dealing with their Medicare Advantage plans.

These plans often send classy color brochures in the mail to seniors approaching 65, inviting them to a free lunch to hear all about the excellent care that they supposedly will receive when signing up with these health plans — all with no extra monthly premiums! Both my parents fell for the promises offered by these “free” plans.

As you wrote in your response, there are serious and inconvenient limitations to the quality of care and the hospitals and doctors covered in these networks. It was frustrating.

My mother’s primary care doctor always seemed exhausted and never explained anything correctly. He seemed to be annoyed when we asked him to repeat information. My dad’s plan told him it was not contracted with the hospital closest to him and referred him to a hospital much farther away. His primary care physician was rude, disrespectful and uncaring.

As my father’s health advocate, I was always arguing with his insurer. My dad became depressed at the poor quality of care and the lack of support from this company. I think he just gave up. He passed away in 2018 of prostate cancer, which had spread into his lower back. Had he received proper testing when it was supposed to be done, the cancer may have been caught early and treated. It was too far gone to treat by the time it was diagnosed.

If you stay with traditional Medicare, there are supplemental health plans that cost a few hundred dollars a month. I have heard from friends and relatives that the care is better through paid supplemental plans.

Bottom line: You get what you pay for. Probably best to stick with plain old Medicare; you might just live longer.

Answer: Like all private health insurance, Medicare Advantage plans can vary dramatically in quality. You can’t assume that one person’s experience with Medicare Advantage will be the same as another’s.

You can assume, however, that any insurance with lower upfront costs will have higher costs or more restrictions, or both, if you need a lot of care. If you want more freedom to choose your medical providers and you can afford the premiums, traditional Medicare with a supplemental policy may be a better fit.

Q&A: Part D premiums can vary widely

Dear Liz: Regarding Medicare, there is one more point I think you need to tell readers, and that is the high cost of Part D prescription drug coverage for people who choose original Medicare. For example, if you need just a few expensive drugs that are “Tier 3″ or higher, and coupled with the monthly fee, you can easily pay $3,000 a year or more. I am not saying original Medicare is bad. On the contrary, it gives you great freedom of health choice. However, Part D is expensive.

Answer: Part D coverage, like Medigap supplemental plans and the all-in-one Medicare Advantage plans, is offered by private insurers. Part D premiums and coverage can vary tremendously from insurer to insurer. Even with the same insurer, which drugs are covered and how they’re covered can change from year to year. That’s why it’s so important to shop around every year and to be prepared during open enrollment (which starts Oct. 15 and runs to Dec. 7) to switch to a better plan.

Q&A: Medicare Advantage plan downsides

Dear Liz: You recently wrote about Medicare Advantage plans, which often cover things like dental care, hearing and vision that traditional Medicare does not. You mentioned that the plans have networks of providers, but people should know that those networks don’t always include the experts they may need if they develop serious health issues. The plans themselves can have copays that make it expensive to get sick. If people want to switch to traditional Medicare and get a supplemental Medigap policy, they may face medical underwriting that could increase their costs.

Answer: Medicare Advantage plans are sold by private insurers as an all-in-one alternative to traditional Medicare. The plans are certainly popular — the percentage of Medicare beneficiaries who sign up for Medicare Advantage has been steadily increasing over the years, in part because these private plans seem to cover more. But the plans can vary widely in the breadth of their networks and how they share costs with beneficiaries.

Once you’ve signed up for Medicare Advantage, switching to traditional Medicare can be problematic, as you noted. Insurers aren’t required to cover you the way they are when you first enroll. Some may decline to offer you a Medigap policy or may charge you more, based on your health.

Q&A: Medicare is complicated. Here’s how it works

Dear Liz: My husband and I are in our 50s and have widowed moms in their 80s. We always understood that when you begin taking Medicare, you are required to choose a plan such as SCAN or Blue Shield and to follow that plan’s benefits and limits. However, my friend who works in a hospital told me that you can elect to have straight Medicare and have no plan limits. Can you explain this?

Answer: What you’re asking about is known as traditional or original Medicare, which consists of two parts. Part A is usually premium-free and covers hospitalization. Part B covers doctor visits and has a standard monthly premium of $148.50.

Traditional Medicare is administered by the federal government and is accepted by the vast majority of medical providers but doesn’t cover everything. For example, beneficiaries must pay deductibles, 20% of Part B services and a portion of hospital stays. For that reason, many people with traditional Medicare also buy supplemental or “Medigap” policies from private insurers to cover these costs. Most Medigap plans, like traditional Medicare itself, don’t have out-of-pocket limits.

By contract, Medicare Advantage plans, also known as Medicare Part C, do have out-of-pocket limits. Medicare Advantage plans are “all in one” coverage provided by a private insurer rather than the government. These plans provide everything covered by Parts A and B of traditional Medicare, and may cover other costs such as vision, hearing and dental that traditional Medicare doesn’t. The plans typically have networks of doctors and other medical providers. If you get care outside that network, you would pay more and sometimes all of the cost.

The final part of Medicare is Part D, prescription drug coverage. That’s purchased from private insurers and may be included in Medicare Advantage plans.

Obviously, Medicare can be complicated, but you can educate yourself at Medicare.gov and download or request the handbook “Medicare & You.”

Q&A: Medicare and Social Security

Dear Liz: If my wife and I wait until we are 70 to collect Social Security but retired at our full retirement age of 66 and 2 months, would we still be able to get Medicare for those 3 years and 10 months before we reach 70?

Answer: You’re eligible for Medicare at age 65, which is typically when you should sign up. Delaying can incur penalties you’d have to pay for the rest of your life.

People receiving Social Security benefits at 65 are signed up automatically for Part A (hospital coverage) and Part B (which pays for doctor visits), with the Part B premiums deducted from their benefits. If you’re not already receiving Social Security, you’ll need to contact the Social Security office, which manages Medicare enrollment, to sign up and pay the Part B premiums.

Q&A: Future home sale affects Medicare

Dear Liz: I am 65 and have a very low income but will be selling my home of 25 years soon to downsize. How will the one-time capital gains affect my Medicare payments, which are currently at the minimum? Can I share with the Social Security office that this is a one-time event and that the following years will all have a very low income stream? Will they adjust my payments up one year and back down the next?

Answer: You can exempt up to $250,000 per person of home sale profit from capital gains, so only profit above that amount would be added into your modified adjusted gross income to determine your Medicare premiums. There’s a two-year lag, so if you sell your home this year and report it on the tax return that’s due next year, your premiums will increase the following year (in your case, in 2023).

As noted in a previous column, you can appeal the increase if your income was affected by certain life-changing events including marriage, divorce, death of a spouse, work stoppage or reduction, loss of income-producing property (because of a disaster or other event beyond your control), loss of pension income or an employer settlement payment because of an employer bankruptcy or reorganization. If you don’t qualify to appeal, the increase would only be for one year and your premiums would return to normal afterward.

Another option is to structure the deal so you receive the payout over time, rather than all at once, but consult an accountant or financial planner before proceeding.

Q&A: Windfall creates Medicare headache

Dear Liz: A couple of years ago, I was forced to receive a windfall by the sale of a company in which I held stock. Besides taking a huge tax hit, I just got my Social Security estimate for 2021 in which my Medicare bill went up by 47%. This year my income will go back down to normal levels. Is there any way to convince Social Security that this was a one-time event and it shouldn’t adjust my Medicare premiums?

Answer: There’s typically a two-year lag between receiving a windfall and potentially having your Medicare premiums raised because of IRMAA (Medicare’s income-related monthly adjustment amount). You can appeal the increase if your income dropped in the meantime because of one of the following life-changing events:

Marriage
Divorce or annulment
Death of a spouse
Work stoppage
Work reduction
Loss of income-producing property (because of a disaster or other event beyond your control, not due to a sale or transfer of the property)
Loss of pension income
Employer settlement payment (due to employer’s bankruptcy or reorganization)
If any of those circumstances apply, you can call Social Security at (800) 772-1213 to arrange an interview. Alternatively, you can download form SSA-44 from the web and mail it in. You will need to provide proof of the event, such as a death certificate, divorce decree or documents from an employer.

Q&A: IRMAA is not your friend

Dear Liz: My wife and I retired in 2019 and ran into IRMAA — Medicare’s income-related monthly adjustment amount, which increased our monthly premiums. I thought I’d done such a good job budgeting for retirement but missed this. A lot of couples have their best income years at the end of their career and then get blindsided by the cost of Medicare and the adjustment based on their previous income. I will say that the folks at the local Social Security office were very helpful, and they supplied us with forms for an exception based on our new income.

Answer: IRMAA can boost premiums substantially for singles with yearly income above $87,000 and married couples with incomes above $174,000. The increases for Medicare Part B, which covers doctor’s visits, range from $57.80 to $347 a person per month. The surcharges for Part D, which pays for prescription drugs, start at $12.20 and top out at $76.40 a person per month.

The adjustments are based on your income two years prior (so 2018 income determines 2020 premiums). You can appeal the increase if you’ve experienced a life-changing event. Retirement with a subsequent drop in income can be one such event. So can other work stoppages or reductions, marriage or divorce, the death of a spouse, loss of income-producing property or loss of pension income.

Even without IRMAA, healthcare costs can catch many newly retired people by surprise, especially if they previously had generous employer-subsidized coverage. Medicare doesn’t cover everything; it has deductibles and co-pays in addition to premiums, and excludes most vision, hearing and dental expenses.

How much you pay out of pocket depends on your health, where you live and what supplemental coverage you buy. A study by Vanguard and Mercer Health and Benefits estimated that a typical 65-year-old woman in 2018 could expect to pay $5,200, but her costs could range from $3,000 to $26,200. (The researchers say a 65-year-old man’s costs are typically about 3% lower.)

Q&A: How Medicare, COBRA interact

Dear Liz: You recently wrote about how Medicare coverage interacts with employer coverage. My husband will retire next year at age 65. His company has over 20 employees, so it’s considered a large company plan that won’t require him to sign up for Medicare. Is it better for him to elect family COBRA coverage for 36 months and defer Medicare coverage, since his company healthcare plan will be superior to Medicare? Can he elect Medicare coverage once COBRA terminates? Coverage matters more than costs.

Answer: He shouldn’t put off signing up for Medicare, because COBRA won’t insulate him from penalties.

The previous column mentioned that Medicare Part A, which covers hospital visits, is usually premium-free, but people generally pay premiums for Medicare Part B, which covers doctor’s visits, and Medicare Part D, which covers prescription drugs.

Failing to sign up when you’re first eligible for Part B and Part D typically means incurring permanent penalties that can be substantial. You can avoid the penalties if you’re covered by a large employer health insurance plan — but that plan must be as a result of current employment, either yours or your spouse’s. Once your husband retires, his employment is no longer current, so he should sign up for Medicare to avoid penalties.

If you or any other dependents need coverage, he may end up paying for additional insurance through COBRA on top of what he pays for Medicare. He can have both COBRA and Medicare for himself if his Medicare benefits become effective on or before the day he elects COBRA coverage. If he starts Medicare after he signs up for COBRA, his COBRA benefits would cease but coverage for you and any dependent children could be extended for up to 36 months. Another option to consider would be to cover you and any dependents using a plan from an Affordable Care Act marketplace. You may want to discuss your options with an insurance agent before deciding.

In fact, getting expert opinions is a must, because Medicare rules and health insurance in general can be so complex. Anyone nearing 65 also would be smart to discuss their individual situations with their company’s human resources department and then confirm the information with Medicare before deciding when and how to sign up.

Q&A: Medicare has a prerequisite

Dear Liz: In a recent column, you mentioned that Medicare Part A is free, but that requires 40 quarters (or 10 years) of U.S. employment to qualify. There are, unfortunately, many of us with offshore employment who have found this out too late. Even if one has worked in a country with a tax treaty with the U.S. that allows you to transfer pension credits to Social Security, that will not allow you to qualify for Medicare. I think it would have been very helpful if I had known this about 10 years ago!

Answer: Medicare is typically premium-free, because the vast majority of people who get Medicare Part A either worked long enough to accrue the necessary quarters or have a spouse or ex-spouse who did. (Similar to Social Security, the marriage must have lasted at least 10 years for divorced spouses to have access to Medicare based on an ex-spouse’s record.)

But of course there are exceptions, and you’re one of them. People who don’t accrue the necessary quarters typically can pay premiums to get Part A coverage if they are age 65 or older and a citizen or permanent resident of the United States. The standard monthly premium for Part A is $437 for people who paid Medicare taxes for less than 30 quarters and $240 for those with 30 to 39 quarters.