Medicare won’t cover a procedure I need. Can I get private insurance?

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MIAMI, FL - FEBRUARY 21: Dr. Martha Perez examines Maria Lebron in a room at the Community Health of South Florida, Doris Ison Health Center on February 21, 2013 in Miami, Florida. Florida Governor Rick Scott reversed himself on Wednesday and now is callling for an expansion of Medicaid to Florida residents under the federal Affordable Care Act. (Photo by Joe Raedle/Getty Images)

Aging and retirement expert Phil Moeller answers your questions. Photo by Joe Raedle/Getty Images

Editor’s Note: Journalist Philip Moeller, who writes widely on aging and retirement, is here to provide the answers you need in “Ask Phil.” Send your questions to Phil.

Check out his new Recommended Reading section with links to notable stories and reports at the end of today’s post.


Michael – N.J.: I have Medicare Parts A and B and a Medigap plan. I am 66, and I’m about to start getting Social Security in October. I was diagnosed with multiple myeloma early this year, and found out (too late of course) that Medicare will not cover the stem cell transplant I need from my identical twin brother.

I’m researching adding private coverage, but it doesn’t look promising. I have been reading that private insurers cannot legally write policies if they know you have Medicare. So I am considering dropping Medicare and getting a private plan that would cover this.

However, this looks even less palatable. I understand that to give up Part A means I forfeit future and past Social Security payouts. Also, if I give up Part B and later do re-enroll, my Medigap plan is no longer guaranteed issue.

Am I understanding this correctly? Am I missing any promising loopholes?

Phil Moeller: A spokeswoman for the Centers for Medicare & Medicaid Services confirmed that Medicare generally does not cover these tests. However, as with much of Medicare, there may be an exception for some Medicare beneficiaries with multiple myeloma who require allogeneic hematopoietic stem cell transplantation. The qualifications seem narrow, but you should check them out and follow up if it looks promising.

As for getting private coverage, I doubt you will find any takers. Even if you dropped Medicare and Social Security — which I do not recommend — I know of no private insurer who would take you on with this pre-existing condition. And if you did find one, the premiums likely would be higher than you could afford.

I wish I had better news. I hope you can find the help you seek.


Janet – Fla.: I am a 55-year-old woman. I have been receiving Medicare since 2005 when I became a disability claimant. I work part time from home, but between doctor’s payments and way over-the-top prescription drug prices, I need help. For example, a monthly prescription I used to pay $10 for is now $275 a month! I have prescription and medical insurance with Humana. Am I financially better off to just use my Medicare and not use private insurance? Supplemental insurance seems expensive.

Phil Moeller: Janet, I am so sorry that you are getting hammered by such outlandish price increases for your medications. Unfortunately, you are in the same boat as millions of other Americans. Tell me what drug you’re taking, and maybe we can embarrass the manufacturer like the maker of EpiPens was embarrassed. That manufacturer consequently agreed to make its product more affordable. And its price gouging, by the way, was only 500 to 600 percent. Yours is 2,750 percent!

READ MORE: Did outcry on social media lead to Mylan’s generic EpiPen?

Depending on your income, you may qualify for Medicare savings programs, including its Extra Help program for prescription drugs. Call a Medicare counselor in your state who works for the free State Health Insurance Assistance Program, see if you qualify and get help applying for benefits. In the meantime, you should look at Medicare’s Plan Finder online tool and see if Humana’s price for this medication is what other drug plan insurers also charge where you live. If you can find this medication at lower cost in another plan, you should consider switching to that plan for 2017 during this year’s annual Medicare open enrollment period, which runs from Oct. 15 through Dec. 7.

Another possibility you could consider is shopping for your health insurance on the Florida state insurance exchange created by the Affordable Care Act. While you are eligible for Medicare because of your disability, you do not have to enroll in Medicare until you are 65. The exchange plan may be cheaper than Medicare. The State Health Insurance Assistance Program might be able to help you find out. As for supplemental insurance, it’s not only costly, but it doesn’t even cover drugs.

READ MORE: Is there any relief for astronomical drug costs?


Lisa – Ga.: I am a Social Security Disability Income recipient and hope to move out of the country to Germany or someplace similar in Europe. I am currently 46. I know some countries it is acceptable to relocate on SSDI. I wish to be independent, but the chaos of politics and living where the buses don’t run and in a society that demonizes disability (especially cognitive) is tiresome. I speak conversational German, which I learned after a traumatic brain injury, but before subsequent brain injuries 12 years ago.  If I am receiving SSDI and can speak the language well enough to get by, what happens with my medical coverage? Can I live overseas? Please advise. I was a paralegal as well. I earned that degree in 1999 after my injury in 1996. I understand the law.

Phil Moeller: Lisa, you are already overcoming more obstacles than people without disabilities ever confront. I applaud your desire to be independent. I’m also sorry you’ve had such negative experiences in the U.S. The first part of your question is easy. If you get SSDI, these payments will continue to be sent to you if you relocate outside the U.S. to Germany. Social Security payments are not sent to people in all countries, but they are provided to people in Germany. The agency has an online screening tool that discloses the rules in different countries. However, you must become a legal resident of Germany (see page 6 of this document) for your Social Security payments to continue.

READ MORE: Why doesn’t Medicare cover more for physical therapy?

Even if you can jump through these hoops, getting medical insurance is not such an easy matter. I assume you are now on Medicare. It does not cover medical care outside the U.S. You would most likely need to get health insurance in your new country of residence. This could be a challenge, especially if you do not have a job and would be living only on your SSDI income. I would begin by joining some online discussion groups of ex-pats living in different European countries. There may be a lot of relocation issues you’d face beyond health insurance, and you should take the time to learn about them and plan your move. Next, I’d find a few insurance brokers who specialize in German health insurance. I say “a few,” because you will want to speak to several people to make sure you’re getting the best deal. I wish you the best of luck. Please let me know if I can be of further help.


Christopher – Mexico: I turned 65 in March, and I retired in Mexico about 100 miles south of the border. I began collecting retirement benefits at 62, and when I turned 65, my online account information was updated to say I was automatically enrolled in Medicare Part A. This is fine with me. In a pinch, I figured I could take a bus or taxi to the border for medical treatment if need be. Here’s my problem: I have never received a Medicare ID card. I used the online service every month to request one to no avail, and I called and spoke with the kind folks at the office in the states and they said they initiated a card replacement. The online service was recently changed to require a cell phone text message so now I can’t even check it out online.

Phil Moeller: Your Medicare card is supposed to be mailed to the address that is connected with your Social Security account. Assuming this address is in Mexico, that’s where the card should go. I’d call or email Social Security again and keep asking them to send you the card. Also, the agency’s requirement that people use a text message as part of its online security process was very short-lived. Many seniors do not have smartphones and do not text. They spoke up, along with advocacy groups, and the agency quickly reversed itself and abandoned the policy. So at least you will be able to access your online account once again.

READ MORE: I can get my Social Security abroad, so why not my Medicare?

Having said this, I don’t know that having a Part A card is going to do you much good. Part A charges no premiums to people who qualify for Social Security payments. That makes it a nice benefit. But it covers only hospital costs. If you really want to have medical treatment when you return to the U.S., you’d also need Part B of Medicare to cover doctors and outpatient clinics. And you’d need Part D to have your prescription drugs covered. Parts B and D both carry monthly premiums. You might get both of these rolled into a low-cost Medicare Advantage plan, but you’d need a U.S. address to document that you’re in the plan’s service area. I’d call some insurance brokers specializing in ex-pat coverage for folks living in Mexico and see what they suggest.


Carol – Ga.: My husband is on disability and will automatically be registered for Medicare next year. Should I still cover him on my insurance at work? Do I need to register him for Parts B and D?

Phil Moeller: It normally takes about 30 months between the date someone is approved for Social Security disability payments and when they can begin participating in Medicare. This is a wonderful safeguard for people with disabilities, providing them guaranteed access to insurance even at very young ages. However, in your situation there is no requirement that he has to take Medicare. Now, I don’t know exactly why you think your husband will automatically be registered for Medicare next year. Perhaps it’s because he’s turning 65 or simply that it will have been 30 months since he was approved for disability. Whatever the reason, he does not have to sign up for more than Part A of Medicare (which he automatically received upon commencing disability payments) as long as he is covered by your employer insurance plan and your employer has at least 20 people on the payroll (there are different Medicare rules for smaller employers). If he receives a Part B Medicare card from Social Security, he should call them and say he rejects the coverage and wants to return the card. Best of luck!


Sherry – Ariz.: I signed up for Medicare when I turned 65 in May of this year. I work full time and I had much better insurance through Walmart. Can I go back on the Walmart insurance during open enrollment this coming fall?

READ MORE: Should you stay on your employer health insurance or get Medicare?

Phil Moeller: As I just told Carol, you do not have to get Medicare when you turn 65 (or 75 or even 85) so long as you have health insurance from your employer and it employs more than 20 people. Walmart, of course, employs a lot more than 20 people! So I don’t know why you signed up for Medicare. Whatever the reason, if you have left the Walmart insurance plan, you may have trouble getting back into it. Before you drop Medicare, talk to someone at Walmart in the employee benefits department and understand exactly what your options are for resuming employer insurance.


Jonathan: In regards to taking Social Security benefits and then being unable to contribute to an health savings account, what’s the policy if a person claims a spousal benefit from Social Security, delays their own retirement benefit until 70 and continues to work?  Can they still contribute to their HSA under this claiming strategy?

READ MORE: Why health savings accounts and Medicare don’t mix

Phil Moeller: No, they can’t. Claiming any benefit, even a spousal benefit, will trigger the mandatory enrollment in Part A of Medicare. This enrollment qualifies as being on Medicare and thus disallows continue contributions to an HSA. Sorry!


Debbie – Wash.: My husband is turning 65 in January 2017, but has been medically retired since 2003. He has had Medicare since then. Since 1991, I have had very good private health insurance that covers both of us. I’m writing because whenever we make appointments or go to the hospital, he is always referred to as a Medicare patient. Sometimes we are told that a physician is not seeing any more “Medicare” patients, even though we have secondary private insurance and Tricare for Life. Is there a way not to have Medicare without penalty and have our private insurance the primary payer? It seems that being a “Medicare patient” only makes things worse.

Phil Moeller: Are you paying any premiums to Medicare for your husband’s insurance? I hope not and that the only kind of Medicare he’s had is premium-free Part A. As I’ve told other readers in today’s column, he does not have to have Medicare so long as he is covered on your employer’s plan. Now, I can’t tell for sure if you are still actively employed or whether your “very good private health insurance” is actually a retiree insurance plan. These plans nearly always require a person to have Medicare when they turn 65, because the plans become the secondary payer of health claims, and Medicare becomes the primary payer. That’s certainly the case with Tricare for Life. And if you have a secondary private insurance plan, then Tricare for Life would move to third place and wouldn’t pay claims until your primary and secondary carriers had paid their share of covered expenses.


RECOMMENDED READING


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How to include your digital assets in your estate plan

It’s hard enough to get your final wishes properly expressed in your will. Now, you have to worry about your digital afterlife as well! However, what used to be an oddity is moving mainstream. Here’s a helpful “how to” piece about making sure your Facebook page has a final resting place as nice as yours. (Source: Andrea Coombs for MarketWatch.)

Tax Credits for Ramps, Grab Bars to Help Seniors Stay at Home

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