My physician isn’t in my Medicare Advantage network. What can I do?
Editor’s Note: Journalist Philip Moeller is here to provide the answers you need on aging and retirement. His weekly column, “Ask Phil,” aims to help older Americans and their families by answering their health care and financial questions. Phil is the author of the new book, “Get What’s Yours for Medicare,” and co-author of “Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security.” Send your questions to Phil.
Karen: I recently enrolled in a Medicare Advantage (MA) plan, partly because a physician that is part of a university-affiliated practice was listed in the network directory. I was a patient of a doctor in the university practice who is not in the network, but I wished to stay in the university practice for continuity of care. The day my coverage began, I attempted to make an appointment with the physician, but was told by the insurance billing office that none of the physicians in their office is in the network! I spoke with a customer service representative from the MA plan and explained the inaccurate, discrepant information in its online directory. When I inquired about disenrolling, I was told I would have to write a letter with my reasons and, further, that if I switched coverage to another plan, I would have to pay a penalty for a lapse in my Part D drug coverage.
I do not trust the information I am receiving. Is this information accurate? How do I avoid penalties? How do I avoid a lapse in coverage? I don’t want to pay out-of-network charges to continue seeing a physician in the university practice. Is this grounds for changing to another MA plan? It seems unfair that when you enroll in an MA plan you can face a penalty or even lack of any insurance due to the plan’s mistakes.
Phil Moeller: Karen’s letter describes the kind of problem that has given MA plans a bad public image. The plans are increasingly popular, and now serve a third of all Medicare enrollees. They often provide more complete coverage than basic Medicare and usually cost less than having basic Medicare, a stand-alone Part D drug plan, and a Medigap supplemental plan.
A goodly amount of their cost savings stems from their requirement that plan members use doctors and hospitals in their provider networks. Here, the accuracy of provider directories has been a problem for some Medicare Advantage plans. They have been criticized for this problem and are taking steps to improve the completeness and accuracy of the directories. Unfortunately, it’s very hard if not impossible for consumers to know ahead of time which plan networks are likely to be inaccurate. For that reason, I urge people to call their preferred health care providers ahead of time, and ask them if they are in a plan’s network.
As to your exposure to late-enrollment penalties, I don’t have enough information from you about the timing of your application for the MA plan to be able to comment with certainty on whether the MA plan was justified in what it told you.
If your enrollment in Medicare was the result of you turning 65, your initial enrollment period should have been seven months, including the three months before your birthday, your birthday month, and three months after your birthday. If your enrollment was the result of leaving a job after you had turned 65, you should qualify for a special enrollment period lasting eight months after the end date of your employer health coverage.
I mention this because your window for getting a Part D drug plan might still not have closed, meaning you would not face late-enrollment penalties if you could get a new Part D plan before your enrollment period ended. Part D penalties begin kicking in once your enrollment windows are closed and you’ve gone 63 days without Part D coverage. So, even if your enrollment window has closed, disenrolling from your current Part D plan might not trigger a late-enrollment penalty if you can obtain new coverage within 63 days of disenrolling. Of course, I don’t know if any of this is relevant to your situation.
This still leaves you with the broader issue of how to hold the plan accountable for misrepresenting the information in its provider directory. In the pro-consumer world I wished we all lived in, this would be a snap. In the real world, it is anything but that. Plans have a lot of leeway in avoiding accountability for these kinds of decisions. I’ll get to possible remedies in a moment.
If seems to me that your first order of business is to find a better package of Medicare coverage. This would include finding a stand-alone Part D drug plan that will take effect quickly and thus allow you to avoid the late-enrollment penalty. The penalty, by the way, is only 1 percent a month tacked on to your Part D premium. So, it’s not a lot of money. But it lasts the rest of your life and would be nice to avoid.
I would also call Medicare (1-800-MEDICARE) and find out how quickly your basic Medicare coverage would kick in, and thus how soon you could see your preferred doctors and be covered. Get ready for some frustration here, as it can take a while for this coverage to take effect.
In the interim, you may face the unpleasant choice of either paying out-of-network rates or going without care.
Once you’ve attended to these needs, you can explore remedies for your plan’s mistakes. I work with several nonprofits that provide consumer Medicare advice, and might be able to work with you to redress the problems you’ve encountered. The State Health Insurance Assistance Program (SHIP) is often the first place to go, although it is more focused on explaining how Medicare works than dealing with private insurance companies. The other two are the Medicare Rights Center and the Center for Medicare Advocacy.
Please let me know how things go. If you discover an effective way to deal with the errors in your plan’s provider directory, I’d like to share that knowledge with other readers.
Deborah: I know that parents can get Social Security benefits for their children in certain situations. But what about grandparents? My husband and I are raising our grandson because his mother and father have abandoned him. He is 8 years old and has only seen his father maybe three times, and I think that was around 2012. He doesn’t call or write him. His mother lives in the same town as us, a tiny town of about 300 people. But everyone else comes before her own son. Ultimately, we would like to adopt him but we don’t have the money to do so right now.
Phil Moeller: I am so sorry you and your grandson are having to go through this. If you can demonstrate that your grandson is living with you and that you are his primary caretaker and pay for his needs, he should qualify to file for benefits based on one of your earnings records, presumably that of the higher earner. In order for him to file, the person on whose earnings record he is claiming must already have filed for their own retirement benefit. I suggest you call Social Security and find out specific requirements to establish your eligibility for benefits for your grandson. You and your husband also should determine the best Social Security filing strategy – one that reflects your longer-term needs as well as those of your grandson. If you run into any obstacles, please let me know.
Bob – Ga.: I’m unclear on the dental work that Medicare covers. We are retired and have traditional Medicare and a letter F Medigap policy. We have believed that we could easily pay out of pocket for what we consider routine dental work such as regular cleanings and fillings, so we did not get dental insurance when we retired. Recently my dentist became concerned about a precancerous spot on my tongue. Suppose I need surgery to remove a benign growth on my tongue or for oral cancer? Would that be covered by Medicare? I know the work must be done by someone who accepts Medicare. But does it matter whether a dentist or physician performs the surgery? Or where the surgery is done? In general, what diseases of or injuries to the mouth/teeth/jaw area would not be covered?
Phil Moeller: You are correct that Medicare does not cover routine dental care. Further, while Medicare generally does cover medically necessary care, this is not always the case with dental work. So, I would urge you to work carefully with your health care providers to get prior approval for any indicated procedures before proceeding.
I wish I could give you a nice and neat list of what “dental” diseases or injuries Medicare does not cover, but its explanation of what is covered is hardly a model of clarity. The agency does have an online form to ask if a procedure is covered. I did not find it useful but perhaps you will have better luck.
It should not make a difference whether a procedure is done by a DDS or MD, but, as you note, you need to make sure the surgeon accepts Medicare rates for his or her work. You also should make sure the facility where the procedure is performed accepts Medicare, and that any doctors assisting your own do as well.
If Medicare does cover a procedure, your Medigap plan should operate normally, paying for covered expenses that weren’t fully paid by your basic Medicare.
Michael – Calif.: I’m retired military and married. We currently have Tricare Prime, and will not turn 65 until 2019. When we do, will we need to apply for Medicare and pay for both Tricare Prime and Medicare? Also, will my wife qualify for free Part A benefits under my Social Security number? The last thing, do we both have to pay for Medicare Part B, or is it a family thing? We are just starting to plan ahead, and don’t understand Medicare.
Phil Moeller: When you turn 65, your Tricare Prime will convert to Tricare for Life, which requires you to get Part B of Medicare. The good news for you is that Tricare does a better job than Medicare of explaining how it works! The bad news is that Part B premiums are $134 a month, and there is no Medicare family plan, so each of you will have to pay. If your wife does not qualify on her own work record for premium-free Part A, she does qualify on yours.
Lastly, even if your wife does not qualify for her own Social Security benefits, she can file for a spousal benefit on your record. She can collect up to half of the benefit you would have been entitled to at your full retirement age, even though you filed for retirement earlier than this and received what’s called a reduced benefit. She will get her maximum spousal benefit if she waits until 66 to file for it, which will be her full retirement age.