Social Security says I owe money for Medicare coverage I didn't get. How do I appeal?
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.
Roger: I turned 65 the second week of January this year, and I had medical coverage through that month. I signed up for Medicare Part A on April 28th but could not move forward because the Social Security Administration's online enrollment forms would not let me continue with my Part B application. I reached them three days later, on May 1, and they told me their records showed that I had signed up for Part B last January!
I sent in letters requesting reconsideration of this decision. I also tried to sign up for a private Medicare Advantage policy but was told I could not do this until I had a Medicare card, which I finally received in late May. Now, I have been sent a bill for more than $1,200, which represents Part B premiums going back to January. Can they do that? Is it legal? I do not have that kind of "extra" cash. Can you help me out, is there something I should know to fight back?
Phil Moeller: What happened to Roger should not stand. His story also is a cautionary tale about how even the most straightforward Medicare applications can turn into nightmares. The initial enrollment period for Medicare when someone without health insurance turns 65 is seven months. For someone born in January, this period would have begun the previous October and extended through April. According to Medicare's enrollment rules, if Roger applied for Medicare in April, his coverage would have been effective in July.
It appears that Social Security, which handles Medicare enrollments, signed him up for Parts A and B when he turned 65. This should not happen, but of course it does in some cases. He should be able to confirm this by signing up for his online Medicare account.
He can appeal Social Security's decision using this form. It is used mostly for other kinds of Social Security decisions, but it also applies to Medicare enrollment decisions (see Title XVII under the form's applicable uses).
Lastly, there are nonprofit organizations that can help people with these kinds of appeals. One that I suggest he contact is the Medicare Rights Center. Hopefully, someone there can help navigate this process.
UPDATE: I mistakenly told Roger that if he applied for Medicare in April, it would be effective in May. That is incorrect. I was looking at the enrollment period for Medicare Advantage plans and Part D drug plans, not for Part B of basic Medicare. Under its rules, if Roger waited until April to enroll in Medicare, his coverage would not be effective until three months later, in July. (The text above has been corrected.)
Roger's question did not mention whether he had begun receiving Social Security benefits prior to turning 65. I should have mentioned this variable. It is standard procedure for Social Security to send its existing beneficiaries a Part B Medicare card when they turn 65. They are supposed to send the card along with an explanation of the agency's action. If Roger did receive such a mailing, he would have been able to reject Part B without future problems.
One major real-world issue with such automatic enrollments is that people who are not expecting them may ignore the Social Security mailing and throw it away. So, if Roger was receiving Social Security benefits but not expecting a Part B card, he may have simply missed the agency's mailing. Of course, I don't know if he was in this situation. But many people are, and it would have been a good idea for me to mention it.
Thanks to the Medicare Rights Center (MRC) for noting these matters. I told Roger he might want to call the MRC to help him work out his problems. Clearly, I should have taken my own advice!
Glen: I am turning 65 and have read your book on Medicare. But I seem to have gotten lost in the weeds on a really basic question. If I initially enroll in a Medicare Advantage plan, do I have the option in future years to change to a Medigap plan? What about the other direction, if I enroll in a Medigap plan initially, can I change to a Medicare Advantage plan in future years? If so, are there any negative consequences for doing so?
Phil Moeller: Well, there are a lot of weeds in the Medicare garden! But, yes, you do have the freedom during Medicare's annual open enrollment season (Oct. 15 – Dec. 7) to switch plans as you suggest.
However, I would caution you that later finding a good Medigap plan might be difficult. During a person's initial enrollment window for Medicare, they enjoy guaranteed access rights to Medigap policies that prevent insurers from refusing to cover them or charging them higher rates due to their age or any pre-existing health conditions.
This period normally lasts only six months. Afterwards, Medigap insurers may charge you more or even refuse to sell you a policy. This doesn't always happen and may never be a problem for you. But it's a possibility that I feel people should know about ahead of time. For more details about guaranteed issue rights, see page 21 of Medicare's 2017 Medigap guide.
Carol – N.C.: What does "homebound" mean as a qualification for home health?
Phil Moeller: This is an easy question with a complicated answer. The Center for Medicare Advocacy, a nonprofit advocate for Medicare beneficiaries, has this explanation, based on a revision of Medicare rules adopted in late 2013:
CMS' New Homebound Policy
As of November 19, 2013, however, CMS will require Medicare beneficiaries to meet two sets of criteria before their home health agency even considers whether they have an ordinary inability to leave home. The new policy states:
For purposes of the statute, an individual shall be considered "confined to the home" (homebound) if the following two criteria are met:
The patient must either:
- Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence
- Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the criteria in Criteria-One, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.
- There must exist a normal inability to leave home;
- Leaving home must require a considerable and taxing effort.
If you want to go deeper into this definition, here is the actual Medicare policy manual explanation.
Scott – Texas: I will turn 66 in January 2018. I have declined my Medicare Part A so that I can continue contributing to my health savings account (HSA). My wife just turned 65, and has been drawing her Social Security for a couple of years. Now, my employer tells me that if my wife is enrolled in Medicare Part A, my contributions to my HSA will drop from $7,750 to $6,250, which is the difference between a family and an individual HSA. Can my wife decline her Medicare and, if so, should she?
Phil Moeller: In order to get any kind of Social Security benefits, a person must also be signed up for Part A of Medicare. There is no way around this. If a person really needs the Social Security payments, I can't conceive of a situation where they'd be better off not filing for Social Security just to maintain participation in an HSA.
From what you say, your employer has been giving your wife a free ride for a while, and should have flagged your HSA contributions right when she began taking Social Security, not when she turned 65. So, in short, your wife cannot really decline Part A. I'd accept the reduced contribution with a nice smile!
Ted – Texas: My wife will be turning 65 next year. She does not have enough work credits here in the U.S. on her own to qualify for Social Security benefits, but she has worked in her home country, Spain, for many years. I am pretty sure there is an agreement to combine work histories to determine benefits but I cannot find any reference as to how her work history in Spain is evaluated to determine U.S. benefits. Also, if my wife applied for Social Security benefits under her combined work history, can she switch to spousal benefits when I apply?
Phil Moeller: Here is an explanation of the formal Social Security agreement with Spain. At first glance, it appears that your wife would be covered by the Spanish retirement system and would be paid by it. Here is what the explanation says about combining work credits:
How Credits Get Counted
You don't have to do anything to have your credits in one country counted by the other country. If we need to count your credits under the Spanish system to help you qualify for a U.S. benefit, we will get a copy of your Spanish record directly from Spain when you apply for benefits. If Spain needs to count your U.S. credits to help you qualify for a Spanish benefit, they will get a copy of your U.S. record directly from the Social Security Administration when you apply for the Spanish benefit.
Although each country may count your credits in the other country, your credits are not actually transferred from one country to the other. They remain on your record in the country where you earned them and also can be used to qualify for benefits there.
If this explanation does not answer your question, I'd call Social Security and see if a representative can help you.
At the time you file for your own benefits, she should be able to file for a spousal benefit if it is greater than what she already is receiving. She would then receive what's called an excess spousal benefit. It would equal the difference between what she was collecting and the higher spousal benefit.
Joel – Mont.: I am turning 65 in a couple months, I have my insurance through my ex-employer that was part of my retirement package. I now am self-employed with no insurance. Do I have to enroll in Medicare?
Phil Moeller: Insurance from an ex-employer does not exempt you from being subject to Medicare enrollment rules when you turn 65. What this means is that if you ever need Medicare, you should consider getting it now, or face lifetime late-enrollment premium penalties. These amount to 10 percent a year for Part B and 1 percent a month for Part D drug plans.
If, on the other hand, your retiree coverage will meet all your insurance needs, you wouldn't need Medicare. However, nearly all retiree health plans are designed to work with Medicare. I suggest you get in touch with your insurer and make sure you understand whether its plan requires you to get Medicare when you turn 65.