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Why don’t ‘Medicare for All’ plans include Americans living abroad?

Journalist Philip Moeller answers your questions about health, aging, and retirement. 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.

Michael – Texas: I’m disappointed in all these ‘Medicare for All’ proposals. They are not really for everyone, because they do not cover Americans living abroad. At least one proposal would even cover undocumented immigrants inside the U.S. But it wouldn’t cover American citizens outside the country! These are people who have paid for Medicare all their working lives, and continue to pay income taxes to the U.S. We also know that foreign care is often much cheaper than care inside the U.S. What is the point of this?

Phil Moeller: I’m with you. I can understand that spending U.S. dollars for overseas medical care may have seemed like a crap shoot decades ago. But the quality of care outside the U.S. has improved so much that we should consider it.

Practically, one serious impediment is that U.S. hospitals and doctors must agree to all sorts of licensing and quality provisions. Providing similar quality-control metrics for foreign-based cases would be tough. I’m not saying it can’t be done, just that it is arduous, and I can’t see the U.S. government providing insurance coverage to health care providers who don’t meet U.S. standards.

How to choose between Medicare and Medicare Advantage

Sandy – Connecticut: I manage my mom’s fiscal life, and I am very confused about choosing between original Medicare and Medicare Advantage plans for her. Mom has been on original Medicare with a Medigap supplemental plan, but she complains it costs too much. She wants to switch to a lower cost Medicare Advantage because at age 81 she is rarely sick.

I think she should stay on the original Medicare and a supplemental plan because it is better coverage. While it may cost more, she can afford it. Who can I turn to in order to help me compare benefits and costs? Please do not say the government websites. They are not helpful! Of all the research I have done, no one seems to have a good answer to this question.

Phil Moeller: The reason it’s hard to find help here is that the best answer depends on detailed knowledge of original Medicare plus many private insurance plans plus an understanding of a person’s health and financial profile.

There are fee-based Medicare advisory firms, but I do not get into the business of recommending one firm over another. I do send people to Medicare’s websites, but you’ve already vetoed that approach.

The State Health Insurance Assistance Program (SHIP) provides free Medicare counseling and is approved by Medicare to do so. I have found that SHIP counselors often are not comfortable providing information about all the private Medicare insurance programs. Just keeping up with original Medicare is a job and a half!

However, I am thinking that a counselor in a SHIP office in your mom’s home state might be comfortable providing you the names of some fee-based Medicare advisors. This is just a guess but will take only a phone call or two to verify.

How Medicare works with employer health insurance

Clairissa – Texas: My mother-in-law is 70 and was just diagnosed with cancer. She works full time and has a health care policy through her job with decent benefits. She has Medicare Part A already. We are trying to make some big choices here that will benefit her. While I don’t believe she will continue to work, she is pretty stubborn and we’re trying to figure out whether she should try to stay at work and keep her health care. If she does, would it make sense for her to still get Medicare, and would it qualify as a secondary payer of her health claims?

Phil Moeller: I’m sorry to hear about your mother-in-law’s health problems. I am comfortable discussing Medicare rules, but I am not an expert on all the different private health insurance plans. So, I strongly suggest that she speak with an employee benefits representative to understand exactly how its plan coordinates benefits with people enrolled in Medicare.

Generally, at workplaces with more than 20 workers, the employer plan remains primary and Medicare is the secondary payer on covered claims. Again, I’d confirm this with the employer plan.

If she decides to retire and rely solely on Medicare, I’d suggest you consider Parts A, B, and D (drug plan) plus a Medigap policy. This can provide near-total coverage of out-of-pocket costs for items covered by Parts A and B.

Part D drug plans don’t provide caps on out-of-pocket payments, and Medigap plans don’t cover Part D expenses. If she needs costly chemo or radiation treatments, these usually are administered in an outpatient setting and thus covered by Part B.

Best of luck to everyone. As I’m sure you are learning, responding to a cancer diagnosis is an “all hands on deck” alert for everyone in the family.

Terrance – Pennsylvania: I turn 65 soon, am working and plan to do so for a couple more months. I have a high-deductible health plan and am thinking of signing up for Medicare as soon as I can so that it can help pay my deductible expenses. Is my understanding here correct?

Phil Moeller: Yes. Medicare can make sense for people with high-deductible plans, either in place of the plan or in addition to it. I advise people to check with their plans and make sure they understand how getting Medicare will affect their plan coverage. Some employer plans, for example, require people to keep their health coverage as a condition of employment. This isn’t common, but it’s important to check.

Gary – Ohio: I signed up for Part B of Medicare thinking my employment was up, but it was extended for 18 months. Should I keep Part B in addition to my work insurance and hope that it covers some expenses, or should I cancel it until I retire?

Phil Moeller: It depends on how much Part B might help you. For example, Medicare as a secondary payer of claims is often helpful for people with high-deductible health plans.

I would speak with someone who can tell you how your employer plan would coordinate coverage for someone with Medicare. If your employer plan would leave you on the hook for substantial out-of-pocket spending, I’d tend to keep B. This also avoids any hassles when you finally do retire, because you will already have Medicare.

Paul – New York: I will turn 65 in July. I have my health insurance through my spouse. It’s a plan with $5,000 annual deductible. Would it make sense to remove myself from this plan and use the money I save to get a Medicare Advantage plan?

Phil Moeller: Getting Medicare certainly can make sense for people with high-deductible employer plans. I suggest that people check with their employer plans ahead of time to understand if there are any negative impacts of ending employer coverage.

Should I use cash to pay for prescriptions?

Pat – Virginia: I have a Medicare Part D prescription plan, and have found that some of my prescriptions are far less expensive when I pay cash or utilize a site like GoodRx. Although this feels good in the moment, am I shooting myself in the foot, as these don’t count against my deductible?

Phil Moeller: It’s always wise to check but the answer usually is “probably not,” especially if you’re making claims for other drugs that do count toward your deductible. The tougher call is when you’ve satisfied the deductible. At that point in the year, if the prescription in question is a brand-name drug and will cost less than 25 percent of the stated price, paying cash continues to make sense. If you’re taking a generic drug, the comparable figure would be 37 percent of the stated price of the drug used by your Part D insurer.

Otherwise, you should use your insurance plan, at least until your out-of-pocket spending for the year has totaled $5,100. At that point, you will enter what’s called the “catastrophic” phase of your plan’s coverage and will pay no more than a few dollars per prescription with a ceiling of no more than 5 percent of a drug’s stated price.