Ask Liz Weston

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health insurance

Q&A: Getting an HMO to cover an outside specialist

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Dear Liz: You’ve written about health maintenance organizations and how they may not cover care outside their networks. Be aware that HMOs will sometimes cover specialists outside of their network, especially in cases where they don’t have that type of specialist, or for an unusual condition needing a second opinion. It doesn’t hurt to ask! I did that when I knew that I should see an orthopedic oncologist to evaluate my scans recently, and my HMO did not have that specialist. I found that type of doctor, and then requested a referral and obtained it, and so it was totally covered. I also did that in 2007 when I had a similar condition needing surgery, and I even had surgery in a hospital different from the one that my HMO normally used, all totally covered.

Answer: Thanks for sharing your experience! HMOs typically don’t cover out-of-network care except in emergencies, but there may be exceptions. HMO members should educate themselves about their plan’s coverage and learn how to advocate for their care. It can also help to have a primary care physician who understands the system and is willing to ask for exceptions to HMO rules when appropriate.

Q&A: Be aware of these issues when switching between Medicare Advantage and Medicare

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Dear Liz: I am planning to retire this year. If I choose a Medicare Advantage Plan, am I able to switch back to original Medicare without paying a fine?

Answer: Medicare won’t charge you extra, but you won’t necessarily have “guaranteed issue” rights for a Medigap supplemental policy. If you want to switch after the first 12 months, you could pay a lot more for this important supplemental coverage.

To recap, Medicare Advantage plans are the all-in-one alternative to original Medicare.

Medicare Advantage plans may offer types of coverage that original Medicare does not, such as hearing, dental or eye care. Many people like the fact that their Advantage plans seem to include more than original Medicare, and do so for a low or even no additional monthly premium.

But Medicare Advantage plans are offered by private insurers, which typically have networks of medical providers. These networks, as well as other benefits, can change from year to year. If you get care outside the networks, you typically pay more — sometimes a lot more. The rap on Medicare Advantage plans is that they can be great when you’re healthy, but depending on the plan may not be so great if you get sick.

With original Medicare, benefits remain the same and you can use any provider that accepts Medicare (the vast majority do). But original Medicare coverage has significant gaps, which is why you’ll need a Medigap plan offered by a private insurer.

If you opt for original Medicare when you are first eligible, insurers are required to issue you a Medigap policy and can’t charge you more based on your health status. Without guaranteed issue, an insurer can refuse to write you a Medigap policy or charge you a lot more.

You also have guaranteed issue rights if you buy a Medicare Advantage plan when you first become eligible for Medicare, but decide within 12 months to switch to original Medicare.

Q&A: Navigating the maze of government assistance for an adult child

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Dear Liz: I have a daughter who is 21 and a single mother with a 1-year-old. She has been diagnosed with borderline personality disorder and major depressive disorder. She hasn’t worked since high school and can’t hold a job. She is no longer a dependent as of this year. My question is what assistance is she eligible to apply for? She already is with WIC and getting benefits for the baby. She’s a mess and I’m having difficulty understanding what she can apply for, and what is realistic in terms of Supplemental Security Income, disability, housing assistance and so on.

Answer: Government benefits can be a nightmarish maze to navigate, but you and your daughter may be able to find your first guide in the WIC program. WIC — which is formally the Special Supplemental Nutrition Program for Women, Infants, and Children — provides low-income women and children with supplemental food and nutrition counseling. WIC also provides screening and referral to other benefit programs that could help your daughter and grandchild.

Another resource is the benefits finder tool at USAGov, the official site of the federal government. Start at https://www.usa.gov/benefit-finder.

You didn’t mention health insurance, but making sure your daughter and her child have coverage is crucial. With medication and counseling, your daughter could stabilize enough to become employable and start to build her young life. Under the Affordable Care Act, she can continue on your health insurance until age 26 even if she’s not a dependent for tax purposes. Otherwise, check the health exchanges at https://www.healthcare.gov/. Please act quickly, as open enrollment ends Dec. 15.

Q&A: Skipping Medicare drug coverage now can mean paying more later when you do sign up

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Dear Liz: I did not enroll in Part D prescription coverage when I enrolled in Medicare in 2005 because I was not taking any prescriptions at the time. When I enrolled a few years later, I was penalized $11 per month for late enrollment and I must pay this penalty until I die. What is the reasoning and logic behind this rule except to benefit the insurance companies? I’ve complained to Medicare.

Answer: You can complain until you’re blue in the face, but this is how insurance works.

Insurers — and the largest payer of healthcare services, Medicare — need a large pool of healthier people paying premiums to offset the costs incurred by the sicker ones. If only sick people bought insurance, premiums would skyrocket, making healthcare even more expensive than it already is.

Q&A: How your health insurance costs could rise because of a Roth IRA conversion

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Dear Liz: With the recent stock market correction, I am considering doing a Roth conversion on an existing IRA now that it is worth less. I can handle the accompanying income tax hit. But while I see plenty of ink spilled on how a Roth conversion can increase Medicare premiums, what about Affordable Care Act costs? Is it the same story there: Will a one-time income spike this year due to Roth conversion impact what I pay all next year for ACA health insurance?

Answer: Potentially, yes. Roth conversions count as income for Affordable Care Act subsidies, so a large enough transaction could increase the premiums you pay.

A conversion allows you to transfer money from a regular IRA or 401(k), which would be taxable in retirement, to a Roth IRA, which would be tax free. If you expect to be in a higher tax bracket in retirement, conversions can make sense — you’re paying income taxes at the lower rate now, rather than the higher rate later. But obviously higher health insurance premiums would offset some of that benefit.

A tax pro can help you model conversions of different sizes to see the effects on all your finances, not just your tax bill. It’s possible that a partial conversion could help you take advantage of the current downturn without dramatically increasing your health insurance costs.

Tuesday’s need-to-know money news

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Today’s top story: How to get therapy when cost and access are a barrier. Also in the news: Mortgage rates stay on the escalator in July, the NerdWallet small business financing index, and how to find out what your health insurance will pay beforehand.

Getting Therapy When Cost and Access Are a Barrier
Many things can prevent you from getting therapy or other mental health treatment. Thankfully, there are ways to access care within your budget.

Mortgage Rates May Stay on the Up Escalator in July
Mortgage rates are likely to rise in July, extending a seven-month streak.

NerdWallet Small-Business Financing Index: Businesses Are Steady Amid Worries
New index measures delinquency rates, new loan volumes and optimism among small-business owners.

How to Find Out What Your Health Insurance Will Pay Beforehand
A new federal law about price transparency just went into effect—but good luck making use of it.