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I had surgery out of state. Why is Medicare refusing to pay?

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 “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; and he will answer as many as he can.

Jerry – Colo.: I recently traveled to Arizona, which is out of the service area for my insurance. I had to have knee surgery. While the doctor and surgery center understood that I was out of my insurance service area, they immediately accepted my Medicare A and B. Now my insurance billing says that Medicare will not cover this? Is there an appeal process?

Phil Moeller: You certainly can appeal this, but I am not hopeful you will get relief. Your note doesn’t say what kind of Medicare coverage you have. If you have basic Medicare (Parts A and B), you should be able to see any doctor in the country who accepts Medicare’s payment schedule, and Medicare will cover you.

On the other hand, the story may be different if you have a private Medicare Advantage (MA) plan. Your note makes reference to being out of your service area, so I’m guessing you have an MA plan. Even though you are required to Parts A and B before getting an MA plan, it has different rules and may not cover you for health care outside your service area.

So, while folks in Arizona were happy to accept your Medicare, they were not the decision makers on whether you were covered.

Every time Medicare rejects a claim, it should be providing you with a form that tells you how to appeal the denial. If the rejection came from your private insurer, it also should provide guidance on how to appeal.

Andy: My wife passed away at age 64 back in 2014. She had been collecting Social Security for about a year and was making about $1,400 per month. I am 56 and understand I can begin taking a percentage of that at age 60 provided I am unmarried. My first question is what is the percentage I will get? Secondly, will those benefits be reduced since I’m working? I make between $60,000 and $70,000 a year. Third, can you confirm that collecting my deceased wife’s benefits will not affect my own benefits, which I intend to take at age 67?

Phil Moeller: Here is a table showing how your benefits will be reduced if you claim them early. Any benefits claimed prior to your full retirement age (FRA) are subject to reductions due to Social Security’s earnings test. Your earnings are large enough so that you’d likely receive no survivor benefits.

Given this, you might want to consider waiting until your FRA to take a survivor benefit and holding off until 70 to claim your own retirement benefit, which will then have grown substantially from what it would be at your FRA.

Lastly, claiming a survivor benefit will have to impact on the amount of your own retirement benefit.

The final question this week involves one of the cautionary tales that I am sad to report but which people need to know. Failure to understand Social Security rules can have a huge cost. Even when the agency provides bad information, people may still be out of luck. Lastly, it’s important to understand that Social Security policies can be hugely consequential for younger people.

Eric – Mo.: My wife, Katy, has Behcet’s syndrome, as have her mother and late grandmother (and I assume others). We were married in September. Katy is 30. I’m not sure exactly when her lupus-like symptoms first manifested themselves, but she’s had arthritis since about age 12, and suffered from full-time pain since she was about 14. Katy didn’t spend long in the workforce — about three months working in a movie theater, and three more months working before being placed on disability as her mother’s dependent at approximately age 21. We were told before we got married in September — and a couple more times afterward — that Katy would not be losing her Social Security disability benefit or her Medicare. She knew she would lose Medicaid, because of my income.

Sometime in January, her mother saw something on the Internet that gave her some doubt about what we’d been told, and she shared it with me. I did some research, and it looked bad to me as well. So, we called a couple of times, before Katy went in with our marriage license. We actually recorded the end of a phone conversation with a Social Security representative, who said that, because Katy had a childhood disability that continued into adulthood, and because she was an adult (not a minor) when she got married, that she would not be losing her benefits. But when Katy and her mother went in, Social Security did a 180°, and said Katy would be losing her disability benefit and that she did not qualify for Medicare any longer because her own work record was too short to qualify for disability in her own name. In addition, they said she owes them $4,000 for overpayment, which we are disputing because they’d misinformed us.

My wife has been getting infusions every two months to suppress her immune system. Without them, her immune system attacks itself, and she will break out in psoriasis all over her body in just days. These infusions cost $9,000 apiece. That’s $54,000 a year, and that doesn’t include other prescriptions and doctor visits. My gross pay is about $35,000 a year. She takes Tramadol a few times a day, bringing the pain level down to a ‘6’ on good days. Most of the pain is in her wrists. Aside from lupus-like symptoms, she also has arthritis and fibromyalgia. We’re waiting for the paperwork from Social Security turning her down before I can try to enroll her under my insurance. Premiums for her will be exorbitant, if my insurance (or any other insurer) takes her on at all. Is there anything we can do?

Phil Moeller: Under Social Security rules, her eligibility for continued disability benefits ended when the two of you were married. Someone at Social Security made a serious error in telling you otherwise. I suppose you could use this mistake as the basis for an appeal, but I doubt it would do you much good.

Further, as you learned, because she can’t qualify for disability on her own work record, she is no longer eligible for Medicare.

Have you contacted the pharmaceutical companies that produce her drugs? Many of them have patient assistance programs that can help people in the kinds of difficult circumstances in which your wife finds herself. Also, is there any organized group for those with Behcet’s Syndrome that have experience with finding coverage or assistance in paying for meds?

I’d also get in touch with your employer insurance provider to find out if she can be placed on your policy. You might as well find out the good/bad news now. Most of these group plans do not permit discrimination against someone because of preexisting conditions. But I know that employers are tightening up all the time on their plans in an effort to hold costs down.

I’m sorry I don’t have better news.

Eric: I’m not sure if Katy has spoken with the pharmacies about what has taken place. I put her on my health care (to the tune of $400 a month in additional premium) as soon as we got the letter denying her coverage, and we just received her insurance ID card. I’m not aware of any Behcet’s groups. It’s a rare disease; I’ve read that there are only about 25,000 confirmed cases in the entire U.S.

The Social Security office gave us some paperwork to fill out, detailing our projected assets and income vs. expenses. The initial math had me coming out just a few dollars short each month, but I omitted deductibles because I’m not sure how much they are (I mentioned this in the form), and I also completely forgot about household supplies. We’ll have to explain these things when they get a hold of us. Assuming they stick to their decision, I will then look to see if there are subsidies or any other manner of assistance. If not, then I may be working seven days a week for the foreseeable future.