Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.
Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP) and the Medicare Rights Center (MRC).
Sam – Conn.: When deciding on whether to go with a Part C Medicare Advantage plan, or a Medigap plan, or just “Original” Medicare, a major consideration for me is what Medicare plans do my preferred health care providers accept? Are providers allowed by Medicare to pick and choose which forms of coverage they will accept, or must they accept any and all forms if they participate at all?
Phil Moeller: Sam, there are two levels of physician access you need to research. First, nearly all doctors accept Medicare, and nearly all of these also agree to accept the agency’s fee schedule for the rates they charge you (and which Medicare will cover). If a doctor accepts Medicare, he or she cannot discriminate but must accept Medicare patients from all approved Medicare health plans. However, if a doctor’s practice is full and is not accepting new patients, you still may not be able to get access. The second level of physician access occurs at the plan level. Even if your preferred doctors accept Medicare, they may not be included in the provider network of all Medicare Advantage plans available in the ZIP code where you live. In terms of hospitals, the same health-plan access limitations can apply when it comes to Medicare Advantage plans.
GOT MEDICARE QUESTIONS?
Original Medicare, by contrast, will let you see any participating doctor or health provider. It does not have restricted provider networks. Some Medicare Advantage plans also provide fee-for-service choices that provide members broader access to providers than those Medicare Advantage plans featuring health maintenance organization (HMO) networks.
Medigap plans, which work with Original Medicare and not Medicare Advantage, will help close coverage gaps in Original Medicare. They thus have no network restrictions and will honor claims from all health providers participating in Medicare.
Betty – Ariz.: I have a complicated medical history. I am now disabled and on Medicare. I have a Medicare Advantage plan, but it only pays 70 percent of my covered expenses and leaves me with a significant bill for many procedures. I tried to get Original Medicare with a Medigap policy, but I could not get approved for either plan G or F due to pre-existing conditions. I very much need to have a plan that picks up more of the gap that’s left in my medical bills. Living on disability leaves me with a very restricted income. I simply cannot meet financial obligations with my current income. Do you have any insight on how I might best correct this gap in my medical bills?
Phil Moeller: Betty, I’m so sorry you’re having a hard time. I am surprised when you say your health plan pays only 70 percent of covered services. Medicare Advantage plans are legally required to offer benefits at least as good as those available from Original Medicare, and it pays 80 percent of covered services. I think you should call a Medicare SHIP counselor in Arkansas at 1-800-224-6330 and review your current coverage. You also should check with the counselor about whether your income is low enough to qualify you for one of several Medicare Savings Programs that can help you with premiums and other insurance expenses. Additionally, there is an Extra Help program that helps pay for prescription drugs under Medicare’s Part D drug program (which I’m assuming is bundled into your Medicare Advantage plan). The counselor will help you compare other Medicare insurance options where you live. And if it turns out that changing insurance makes sense, you can do so during Medicare’s annual open enrollment period, which begins on Oct. 15 and extends through Dec. 7.
Ann – N.Y.: My husband will turn 66 at the end of November, at which time he will start collecting Social Security. He’s been retired for five years. I am 59 and still working. We both have a family high deductible health plan (HDHP) through my employer and his former employer. Since we both have family plans, and I am still working, I fund under my account the majority of the HSA ($5,550 plus an employer contribution of $600 for a total of $6,150). My husband funds his HSA ($1,000 plus an employer contribution of $1,500 for a total of $2,500). Our combined contribution is thus $8,650, which is the maximum allowed by the IRS. My question is, once he starts collecting Social Security in November and thus will not be eligible to contribute to his HSA, what will we be allowed to contribute for this year? And, for next year, since I am still HSA-eligible and have a family plan, can I still contribute the IRS max of $6,650 plus $1,000 (my catch-up)? The reason I enrolled in a family HDHP family plan is to cover my husband so that he can delay enrolling in Medicare, delay collecting Social Security until his full retirement age of 66, remain HSA-eligible until then and finally, not pay any late enrollment penalties when he finally begins Medicare upon my retirement. My question is: if what I am doing makes sense, am I doing anything wrong in the eyes of IRS or the Social Security Administration?
Phil Moeller: Well, Ann, the only thing I am absolutely sure about is that your questions have made the Maven’s head ache very, very badly. First, I am very much hoping that your employer and your husband’s former employer are, in fact, the same firm. Otherwise, I do not understand how he can avoid the requirement to have signed up for Medicare at age 65, or how he’s able as a retiree to contribute to an HSA. I bounced this off the IRS and they are puzzled as well and doubt your husband is eligible to contribute anything to an HSA. But as I frequently note, omniscience is not part of my job description. Perhaps you both somehow have individual HSAs that are part of family plans.
According to IRS Publication 969, which deals with these matters, the two of you are free to allocate shares of your annual contributions as you wish. Whether your husband can contribute now or not, he won’t be able to when he files for Social Security in December. At that time, you would be free to boost your own contributions so long as you remain in a family plan. So yes, you can contribute up to $7,650 next year all by yourself. However, I’d check with your employee benefits department to make sure that you will retain family status for your HDHP contributions next year. The annual limit on what is called “self-only” plans is much smaller.
As for your husband’s eligibility for subsequent penalty-free Medicare enrollment, there generally is no problem with that as long as he continues to be covered on your employer plan, you are an active employee and the plan certifies that its drug coverage is “creditable” — at least as good as a Medicare Part D plan. Employer plans are supposed to provide such certifications annually.
Joy – N.Y.: I took a free trial offer for a Humalog KwikPen insulin pen to the pharmacy but discovered that Medicare recipients aren’t eligible. I’ve also tried to use several pharmacy discount cards that came in the mail with the same result. Why is that?
Phil Moeller: The short and sad of it is that Medicare prescription drug plans (Part D) do not work with discount cards. Sorry!