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How does a married couple make the most of Medicare and an employer health plan?

Robin – Fla.: My husband is retired and now covered under my employer group coverage. He will turn 65 in May, and I am 58. His coverage makes our health plan much more expensive than to cover just me. Last year, we opted for the lowest-priced plan, which still costs $640 a month and doesn’t cover much.

I’d like to get better coverage for myself. Our open enrollment is coming up and I’m sure our plan will cost even more this year. We can’t afford both of us on the higher plan, and I won’t be able to drop him from my employer plan next May when he turns 65, so whichever way we choose in November, we’re stuck with it until 2019!

If we do drop him from my plan and he gets Medicare, I simply don’t know how we will afford Medigap for him. As I understand it, Medicare part C plan premiums are based on income. Last year, due to bonuses, was my best year ever; this year I will not qualify for that and could conceivably make a little over half what I did last year. The Medigap premiums may take close to half of his meager Social Security if they base premiums on our joint 2017 income!

We are seriously considering getting a divorce, and being married nearly 37 years, just so that we can afford health insurance!

Phil Moeller: First off, I am sorry you’re having such a hard time. I don’t know that you need to divorce, but it is such a sad state of affairs where people have to even consider such a thing.

Your proper course of action likely depends on the specifics of your employer plan, your health needs, and your personal finances. While you have provided me some of these details, I do not know enough to provide you detailed advice. This is complicated stuff.

However, based on what you’ve told me, I do have some thoughts.

First, and with no offense intended, I’m not sure you fully understand the types of Medicare you mention in your note. Medicare Part C refers to Medicare Advantage plans. These plan premiums are not based on income.

To qualify for a Medicare Advantage plan, a person first must have Part B of Medicare, which covers doctors, outpatient expenses, and medical equipment. Part B premiums are based on income, and people with high incomes have to pay surcharges for both Part B and Part D of Medicare, which covers prescription drugs. However, as you state, your income is no longer high enough to trigger these surcharges. Here is an explanation of how the surcharges work, here are details on how to appeal them and here is the form to use to request an exemption from those surcharges.

Your note also mentions Medigap coverage. Medigap plans are sold by private insurers, and cover things that are not covered or not fully covered by people with basic Medicare, which consists of Parts A and B of Medicare. While it may be nice to have a Medigap plan, many people do not, and live with the coverage provided by having A and B, and a stand-alone Part D drug plan.

I do not understand why your health plan won’t let your husband drop coverage next May when he turns 65. It is his right at that age to get Medicare and I would push back on the health plan’s authority in claiming he cannot be dropped from your policy.

If the plan still insists he must be covered for the entire year, I’d drop him from the plan and get the improved coverage that you would like for yourself. He can enroll in Florida’s Affordable Care Act insurance exchange. It must provide him coverage and if his health is good, he can get a very inexpensive plan until he turns 65 and enrolls in Medicare.

Given that money is really an issue for you, you might consider at that time having him get an inexpensive Medicare Advantage plan. This plan will cover the same things as Parts A, B, and D. It also would provide a ceiling on his total out-of-pocket health spending, thus making a Medigap plan unnecessary (in fact, people with MA plans are not even allowed to get Medigap policies).

MA plans often restrict people to using only the doctors and hospitals in the plan’s provider network, so it’s important to do some homework to make sure your husband’s doctors are in the plan he chooses.

Florida has many low-cost MA plans. You can use Medicare’s online Plan Finder to research what the 2018 plans look like. Next May, your husband can sign up for an MA plan. His enrollment period will begin in the third month prior to his 65th birthday month, and if he acts promptly, his coverage should commence when he turns 65.

Lastly, if you can’t get out of paying high-income surcharges for his Medicare plan, you could consider filing separate tax returns so that your higher income won’t affect his Medicare premiums. However, you should be careful that this doesn’t cost you more money. His lower income, for example, may be shielding your higher income from some taxes if you are filing a joint return.

Sierra – Texas: At age 33 I became totally disabled and unable to work. I eventually ended up on Social Security disability insurance and got Medicare. Now, I am married and my husband’s employer has health benefits. I have heard that I am required by law to be covered by my husband’s health insurance as my primary insurance with Medicare as my secondary insurance. Is this true?

Having employer insurance and Medicare has become a huge problem. I have been having issues with both insurances paying out for medical procedures, appointments, and medicines. While they argue about which one is supposed to pay, I wind up receiving less coverage now that I have both insurances then I did previously with one insurance. Would it be cost effective to get a third insurance? And how do I get the primary plan and Medicare to accept their shares of my medical expenses? For example, my employer plan won’t cover a particular medicine because they want Medicare to pay. Medicare has yet to pay for anything, even though I have been on disability and having money taken out to pay for it.

Phil Moeller: First off, you are not required by law to be covered on your husband’s health plan. This is your choice.

With more than one insurer, coordination of benefits can be a major hassle, especially in the early stages of having two insurers. I have no instant wisdom to dispense here. Just keep good records and be prepared for a lot of paperwork and time spent on hold during calls to insurance representatives. Sorry, but that’s reality!

I do not know what kind of Medicare coverage you have — basic Medicare or a Medicare Advantage plan? If you have basic Medicare, and I’m guessing you do, you can get a Medigap supplemental policy to cover things that basic Medicare does not cover. However, Medigap policies can be expensive. Also, do you have a Medicare Part D drug plan?

If I were you, I would call the benefits folks at your husband’s plan, tell them you’re considering disenrolling from Medicare, and ask them if their plan would then cover you as fully as it covers your husband. It should. If for some reason they say it won’t, ask them the basis for this position. And please tell me. I need to know about such adverse decisions.

If you are not happy with what your husband’s coverage offers on a stand-alone basis, you then could find out how much money your household would save if you opted out of the employer plan. You then can look at a Medicare-only solution and see if it provides the coverage you need at a reasonable cost. My Medicare book goes over various types of Medicare detail, but perhaps asking you to read an entire book is cruel and unusual punishment!

Eugenia – N.Y.: I was born in 1947 and have been paying my Medicare premiums myself since 2012. This year, I applied for my Social Security benefits and when I did, Social Security dropped me from Part B by mistake. Even though the agency has admitted it is at fault, I have been trying for more than six months to get this fixed. It’s been “escalated” twice to upper managers but I still don’t have coverage and am getting desperate. Do you have any help for me?

Phil Moeller: I am so sorry to hear about your problems. People everywhere need to recognize that mistakes like this can happen to them. I wish I had a magic button that could get your situation fixed right away, but I don’t. I would urge you to keep detailed records of your interaction with Social Security, especially anything where they admit it was their fault that you were accidentally disenrolled from Part B.

If the worst were to happen, and you had serious health needs for which you weren’t covered, you at least would have a solid basis to hire an attorney and seek to hold the agency financially responsible for your expenses.

Short of that, it sounds to me like you are doing the right things here to look out for yourself. Please let me know how things turn out!

Sarahkate – Ore.: I went through a professional benefits consulting service when I signed up for Medicare at age 65. I don’t think that it was done properly. I did sign up for Part B plus some other plan – I don’t know if it is “Medigap” or “Medicare Advantage” and I don’t understand the difference between those anyway. And, yes, I have your book and still do not understand! But what has me absolutely terrified is this: I do not know if I have Part D and now that I am 66 if I am going to be knocked financially for Part D forever if I didn’t get it when I signed up? Lastly, if my situation wasn’t complicated enough already, I have begun to claim spousal benefits from my divorced husband. I have a new Medicare card with his Social Security number on it, and my primary physician won’t accept it anymore and will not explain why. I just don’t know what to do. I just don’t understand where to go on from here, or even how to get there.

Phil Moeller: This is where I tell you to do some deep breathing! You can open an online My Medicare account. It should tell you exactly the kind of Medicare coverage you have, including whether you have a Part D plan.

If you have a Medicare Advantage plan, it most likely includes a Part D plan. You need to have gotten Part B in order to qualify for a Medicare Advantage plan, so it’s possible this is what you have.

Medigap plans provide supplemental coverage for people who have Medicare Part A and B coverage. These plans are different from Medicare Advantage plans and, in fact, you can’t use a Medigap plan with a Medicare Advantage plan but only with what’s called basic Medicare (Parts A and B). If you do have basic Medicare and a Medigap plan, then you also should have a Part D drug plan.

Your My Medicare account should tell you these details. If it turns out that you don’t have a Part D plan then, yes, you would face late-enrollment penalties when you get one. They are not particularly large, so I wouldn’t worry about that too much.

Once you’ve seen your My Medicare information, you can call the State Health Insurance Assistance Program (SHIP) with any questions. SHIP is federally funded and provides free Medicare counseling.

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. Send your questions to Phil.