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“Ask Phil,” aims to help older Americans and their families by answering their health care and financial questions. Phil is the author of the 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.
Gail – New Jersey: Our mom is 83 years old. She has bladder cancer that, despite surgery, has spread to her lungs, ribs and pelvic bone. She only has one kidney due to a cancerous mass more than 20 ago, and this one kidney is starting to fail. She has chronic obstructive pulmonary disease with daily inhalers. Since her surgery, she has deteriorated more and more each day. Between my sister and myself, mostly my sister, we have been caring for her the best we can. However, it has come to a point that we need some assistance. She does have a nurse seeing her once a week. We wanted to know at what point would hospice care be considered covered or if she can get just health care assistance in bathing her and helping her with incontinence issues? Please let us know your thoughts and what would or could be covered by her insurance.
Phil Moeller: I’m so sorry to hear about your mom, and wish the best to her, you, your sister and other family members.
Her doctors can recommend hospice if they think she has six months or less to live. This is the “trigger” for hospice benefits. If she survives longer than six months, she can remain in hospice if her doctors issue a new prescription.
Medicare generally does not cover non-medical care to help your mom with what are known as activities of daily living (ADLs) such as bathing, dressing and eating. If your mom’s Medicare coverage also includes a private Medicare Advantage plan, I’d suggest you call that insurer to confirm its coverage rules for help with ADLs.
If your mom’s income is very small, she might qualify for Medicaid, which might cover such non-medical care. Medicaid eligibility and coverage rules vary by state. The State Health Insurance Assistance Program (SHIP) provides free Medicare counseling and should have someone in a New Jersey office who can address state Medicaid eligibility questions.
Vivian – Texas: My mom just turned 90 and pays out-of-pocket for oxygen and home health due to getting denied payment from Medicare. She uses all her fixed income. She is bedridden and in an electric chair. She has an incurable muscle disease and is a heart patient. Who can I contact to see why Medicare doesn’t help with her costs?
Phil Moeller: Unfortunately, Medicare does not cover non-medical expenses, which is why she can’t get home health care. As for her oxygen, I am not clear about that. If her doctor has prescribed oxygen as medically necessary, it should be covered. You can call 1-800-Medicare to ask about that coverage.
If she has a private Medicare Advantage plan, it still should cover everything that basic Medicare covers, although plans generally require prior approval for therapies. If she has only what’s called original Medicare (parts A and B), she can appeal a claim denial. Instructions about how to do so should be included in any claim denials she has received.
Sorry I don’t have more encouraging news. Many people mistakenly think that Medicare covers lots of things that it doesn’t, only to learn the reality of its limitations when they or a loved one is denied coverage.
Brenda – Missouri: My mom lives in Kentucky and needs an aid or nurse to come in once a month to check on her. Does Medicare pay for such service? I have asked her to check it out and all she says is they don’t pay for anything. I live out of state so I’m no help. Is Medicare coverage the same in all states?
Phil Moeller: Generally, Medicare covers medically required things but not help with non-medical care. Unless a doctor prescribes home health care as medically necessary, it won’t be covered.
I am assuming your mom has basic Medicare — Parts A and B. If she has a private Medicare Advantage plan, its rules can be a bit different. In general, however, basic Medicare and Medicare Advantage cover the same things anywhere in the country.
If she has been rejected for coverage, there should be a document trail, either from a Medicare contractor or a Medicare Advantage insurer. These rejections usually include instructions for appealing a denied claim.
If you think your mom’s needs are medical in nature, I’d call her primary doctor’s office and try to discuss this and see if there is a medical basis for having her care covered.
Dave – California: I have three months to go until I’m 70. I hate my job. I’m not as sharp as I used to be at my work as a newspaper reporter, but my boss is a terror. I hate coming to work in the morning. It’s probably bad for my health, which at the moment is good.
If I quit now and don’t wait until I’m 70 to draw my Social Security benefits, will my decision materially affect the size of that benefit? It’s now estimated at $3,084 per month.
Phil Moeller: As a former newspaper reporter, I empathize with how hard life in a newsroom can be these days. If you filed for Social Security now, your benefit would be reduced by 2 percent from what it would be if you held out to age 70. That amounts to $60 a month every month for the rest of your life. So, if you can, I’d urge you to wait, even if it means having to dip into savings.
Andrea: How did the rules on spousal benefits for Social Security change a couple of years ago? Can a younger spouse still file for a spousal benefit when the older spouse begins to receive Social Security and then switch to his or her own benefit later? I plan to begin collecting Social Security soon when I turn 70. My husband will then be 65 years old. Can he collect a spousal benefit at that time, then switch to his own benefit at 70?
Phil Moeller: Under the changes that were made in 2015, the strategy you describe is no longer possible. This hinges on whether your husband was born before or after Jan. 2, 1954. Based on your note, it appears he was born after this date.
If that’s the case, he cannot collect a spousal benefit and defer his own retirement benefit. Regardless of his age when he files for the spousal benefit, he will be deemed under Social Security rules to also be filing for his own retirement benefit. He would then receive a benefit roughly equal to the larger of the two benefits.
If I’ve misunderstood your note, and he was born on or before Jan. 2, 1954, he would still be able to take advantage of the strategy you outlined. If that’s the case, and you have any questions about how to execute this strategy, please let me know and I will explain how this would work.
Jenny – Florida: I receive my own Social Security and the balance of half of my spouse’s benefit. Does the annual cost of living adjustment (COLA) apply for both pieces in terms of helping cover my higher Medicare premiums, or just the COLA on my own my benefit?
Phil Moeller: Whether you’re getting just your own retirement benefit or a higher benefit that includes part of your spousal benefit as well, there is a single annual COLA (2.8 percent for 2019) that applies to your total benefits, and which is available to help pay higher Medicare premiums.
Kathy – Maryland: The rules for Medicare’s high-income premium surcharges do not make sense for married people who file separate returns. I have been separated 24 years. I had a “good” year at work last year and earned $93,000. But my euphoria was cut short when I learned that my Medicare premiums would be something like $500 a month! If I were single, I wouldn’t get hit with that surcharge unless I made more than $160,000, and the threshold for a couple is $320,000. Where is the fairness in this?
Phil Moeller: I am with you. The tables for Medicare’s high-income surcharges seem unduly harsh for folks like you. I have never seen a good rationale for this treatment. Sorry! My only suggested remedy is to call your congressman and senator.
Toby – New York: I sold my house in 2017 after living in it for 55 years. I paid $30,000 more in federal income taxes. I then got hit with a big hike in my Medicare premiums. Is this actually the way it works? Why would I have to pay more since Medicare is a federal program? Can it be protested?
Phil Moeller: Join the club of people who hate Medicare’s high-income surcharges! These are based on your taxable income, so of course people who get hit with the surcharges will also be paying higher income taxes. The logic is that wealthier people should pay more for Medicare than others. I understand the argument, but it hasn’t convinced anyone who has complained to me! The only good news is that the surcharge will disappear when your income declines next year.
Phil Moeller is the author of “Get What’s Yours for Medicare: Maximize Your Coverage, Minimize Your Costs” and the co-author of the updated edition of The New York Times bestseller “How to Get What’s Yours: The Revised Secrets to Maxing Out Your Social Security,” with Making Sen$e’s Paul Solman and Larry Kotlikoff. On Twitter @PhilMoeller or via e-mail: firstname.lastname@example.org.