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My husband needs at-home health services. Where do I start?

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.

Peggy – Ariz.: My husband is at the point with health issues where I need help with his bathing and going to bathroom. He has been diagnosed with prostate cancer, AFib [atrial fibrillation], and severe breathing problems with fluid retention, all of which are being treated somewhat. What are the steps for getting home care with Medicare?

Phil Moeller: I am sorry to learn about your husband’s health problems, and hope things turn out as well as possible.

Medicare does cover at-home care services if they are prescribed by a physician or other licensed caregiver. So, this would be your first step. Medicare does not cover so-called custodial care, so your husband must require medical care.

Medicare requires that people use only agencies it has licensed to provide this care. This would be your next step. Here is an online search tool to help you find an agency near you. If your husband has a Medicare Advantage plan, you should call the plan to see if it has a list of approved home health providers.

There have been reports that people have either been improperly denied this benefit or have had trouble finding a home health agency who will work with them. I would appreciate you letting me know your experience in this regard.

Denise – Mo.: My husband is on my insurance through my employment. He has been approved for Social Security disability and I understand this means he will also be able to get Medicare in a couple of years. Should we drop him from my insurance then and just get a supplemental policy along with Parts A and B of Medicare? My cost for his insurance is about $300 a month.

Phil Moeller: Your question may seem fairly straightforward but what you’ve asked winds up requiring an examination of all Medicare coverage, not just the ones included in your question.

His Medicare Part B will cost $134 a month unless you make a lot of money. Part B only pays 80 percent of covered expenses, so one key question here is whether your employer plan would pay that 20 percent or if your husband would need a Medigap supplement plan to do so. Medigap plans are regulated at the state level. Many states do not require insurers to even sell Medigap plans to disabled persons younger than 65; fortunately, Missouri insurers are required to do so.

Most Medigap plans cost less than $166 a month, which is the difference between what his employer coverage costs and his Part B premium. You can call a local insurance broker and get Medigap quotes. The annual guide to Medigap explains the different types of Medigap plans.

Even if you would save some money by dropping his employer coverage in favor of Medicare, your work is not yet done! Your question did not include prescription drugs. I assume they are covered on the employer plan, but under Medicare, he would need to get a separate Part D drug plan. Monthly premiums vary and average a bit more than $30.

Your question also did not mention getting a Medicare Advantage plan. These plans would charge him a premium on top of his Part B payment, but they usually include drug coverage and also have annual ceilings on out-of-pocket medical expenses that avoid the need for a Medigap plan.

Premiums for most Medicare Advantage plans are cheaper than getting Medigap plus a stand-alone Part D plan. However, they usually require care be provided by doctors and hospitals in a plan’s provider network, and coverage may only be available near where you live.

By this time, you may have regretted even asking your question! I wish Medicare was easier to navigate but at least you still have two years to come up with the right answers. If you need more guidance, you can find it in my book.

Martha – N.Y.: I will soon turn 65. I am fully employed and, because my company has fewer than 20 employees, I plan to sign up for Part A and Part B of Medicare. When I stop working — and I hope to work into my 70s or beyond — will I face problems getting a Medigap supplemental policy? Also, Social Security says I have to pay $134 a month for Part B of Medicare. Since I am not getting Social Security yet, how will this supplemental payment get paid or billed?

Phil Moeller: You ask a great question. If your employer plan will be providing supplemental coverage to your Medicare, you really don’t have a need for a Medigap plan right now. However, the Medicare rules that provide you guaranteed issue rights for a Medigap policy normally expire six months after you get Medicare. If you lose these rights, insurers in some states may be able to charge you more for a policy because of any pre-existing health conditions you have, or even decline to sell you a policy at all.

Fortunately, Medicare rules do not start your Medigap “clock” ticking until you leave your current employer plan. At that time, you will have a Medigap enrollment period during which you will be guaranteed of getting a policy on favorable terms. Your situation is described in detail on page 22 of Medicare’s annual guide to Medigap.

Lastly, because you’re not yet receiving Social Security, you would pay your Medicare premiums directly to Medicare every three months. You should receive payment instructions and should call Social Security if you do not (Social Security handles Medicare premiums).

Eliza: We just found out that my husband needs heart surgery in the near future. He is on private health insurance now but will turn 65 in July and will be on Medicare. What happens effective July 1, since he’ll most likely still be under a doctor’s care and will still need treatment relative to the surgery? He is going to select a Medicare Advantage plan that his doctor and surgeons are in.

Phil Moeller: On paper, all will be fine. If his Medicare effective date is on or before he loses his current insurance, he will be covered for any post-operative care.
In the real world, you will need to spend a lot of time making sure his two insurance plans don’t drop the ball. Due to long delays between a care event and the subsequent insurance billing, you’ll need to make sure that his first insurer pays for covered charges that occurred before his first plan ended, and that such claims don’t get submitted to your MA insurer.

It sounds like his surgery will be done by the same surgeons who will be in his new MA plan, so this should make coordination easier. I’d call the MA plan you intend to join before the surgery, explain what’s going on, and ask for any suggestions or guidance to help you avoid unpleasant surprises.

Thanks for taking the time to write, and best of luck on the surgery.

Mark: My disabled adult son is on Medicaid. He does not work. He recently switched from SSI [Supplemental Security Income] to SSDI [Social Security Disability Income]. We were told he will be automatically signed up for Medicare in about one year, but we are happy with Medicaid and don’t need Medicare, especially the Part B premium, which will diminish his benefit. I am reading that some states’ Medicaid programs will pay the part B premium. I also read that declining Part B could have negative consequences in the long term. What should we do?

Phil Moeller: If your son’s income is low enough, he would be dually eligible for Medicare and Medicaid, and Medicaid should pay for any Medicare expenses. I don’t know where you live, but as you probably know, the states have different Medicaid eligibility rules. So, I would first check with your state’s Medicaid office and see whether your son’s shift from SSI to SSDI will have any impact on his Medicaid eligibility. If you need help understanding your state’s Medicaid eligibility rules, I’d get in touch with a local office of the State Health Insurance Assistance Program (SHIP), which provides free Medicare counseling.