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Why you need to do your doctor research before signing up for Medicare Advantage

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 the new 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; and he will answer as many as he can.

Larry – Texas: The premiums on my teacher’s retirement plan are going up a lot, so I am researching whether to switch from my Medicare Advantage (MA) plan to basic Medicare with a Medigap plan. A friend has warned me that more and more of the really good doctors are not taking seniors on original Medicare due to Medicare’s low pay to the doctors and excessive red tape. Do MA plans pay the doctors more than original Medicare and are they more popular with doctors? With a massive influx of retiring boomers and evidence of a doctor shortage getting worse, what should I do?

Phil Moeller: Generally, any doctors participating in Medicare must agree to accept Medicare rates, including those who work with Medicare Advantage plans. According to recent research, the rates paid to doctors are similar for basic Medicare and MA plans.

Doctors who work with a particular MA plan are members of that plan’s provider network. Because they have agreed to be in this network, your odds of finding a doctor in the plan who will treat you are quite high.

The downside is that MA plans generally only provide insurance coverage if you use doctors in their network, or may charge higher rates for out-of-network care. It is essential that you do research on the doctors in an MA plan’s network and make sure you are satisfied with the quality of care they provide. I realize this can be hard to do, but it is the best way to make sure you don’t sign up for a plan and then discover you don’t like the care provided by the doctors who are available to you.

You are clearly right in being concerned about a worsening shortage of doctors. Having said this, it has long been hard to get an appointment with highly rated doctors, whether a patient is on Medicare or private health insurance.

Joe – Texas: I know that Medicare Advantage insurers get payments from Medicare to help cover my insurance costs. Can you tell me how much Medicare pays my Medicare Advantage insurer for my coverage?

Phil Moeller: That’s a great, and very logical question. However, I don’t know the answer and doubt you could find it!

Medicare Advantage plans receive a “capitated” payment from Medicare per enrollee. The amount of that payment can change based on the measured health of each person covered by a MA plan. Medicare beneficiaries have such health scores, but this information is not publicly available.

In theory, people with adverse scores will be more expensive to insure, justifying higher payments to the plans from Medicare. In practice, some MA plans have been found to have gamed the system by inflating scores to boost their profits.

Having said that, you are pretty much guaranteed of getting any Medicare Advantage plan you want. The plans must accept you regardless of any underlying health conditions. And the rates you pay are not affected by your personal health score. What is affected is the amount of revenue a plan can receive by having you as a customer.

Here is an article about these payments that I wrote as part of the research for my Medicare book. I hope it helps.

David: I am a retired teacher who accepted an early buyout (age 63) that included health care for me and my family for 10 years. I left work with the understanding that I had the group health care for active employees. For seven years now, my school district has paid all claims as if I were an active employee. I recently received a letter from my school district telling me that effective July 1, 2018, my coverage through them will be secondary to Medicare. When I looked into getting Part B of Medicare, I was told I will have to pay a 50 percent penalty on the premium for the rest of my life! Fortunately, I can get full health coverage as a spouse on my wife’s group health plan, which will cover me for the next five years.

When she retires in 2023 and I finally do need Medicare Part B, will they look at the fact that I have had group coverage up until that point and I won’t be subject to the late enrollment penalty? Or, will they look at my gap from age 65-70 and, despite having had group coverage for the period age 70-75 (through wife), assess me the penalty for the age 65-70 gap?

I have spoken with the Social Security Administration and Medicare three times and have gotten three different answers. I am lying awake at night worried about this.

Phil Moeller: Many people have gotten caught in this situation, thinking that retiree health care is the same thing as active employer insurance in terms of avoiding Medicare’s late-enrollment penalties.

You should be able to avoid additional penalties by demonstrating that you have had employer coverage through your wife’s plan for five years. However, innocent or not, I do not know how you would avoid the earlier five-year penalty once you enroll in Medicare.

Also, with apologies for piling on the bad news, there also are late-enrollment penalties for Medicare Part D drug plans. They are less onerous than the Part B penalty, and amount to one per cent of the average national premium for a Part D plan for each month a person is late in enrolling.

I wish I had better news.

Mary – Va.: I started receiving Social Security in 2015 when I turned 62, because I was divorced after 20 years of marriage and needed the income. I understood at the time that I could receive half my ex-spouse’s Social Security when he started drawing it at age 66 which he recently did. But I am now being told different things by Social Security. Last year, I was told that since I had filed at 62, I could not receive a higher amount than what I get now. Then I was recently told that I could file under my ex-husband’s Social Security and get a higher amount. However, I was told that my check would only go up about $30 even though that is not anywhere near half his. I get $700 a month and he receives $2,300 a month. I am confused

Phil Moeller: I am sorry you have gotten messed up by Social Security’s very complicated claiming rules. Unfortunately, these rules inflict a very high cost on people who are forced, as were you, to claim benefits early.

When you claimed your benefits at age 62, not only were they reduced, but this also had an impact on your future ex-spousal benefits.

Because you filed early, you wouldn’t get half of his age-66 benefits but a much smaller percentage. I don’t know the exact numbers, because they are based on your situation. But what Social Security is telling you is similar to what I’d expect.

Again, I am sorry I don’t have better news to share with you.

Here, a reader shares a terrible Medicare and Social Security story with a happy ending. –Phil Moeller

Mary – Ariz.: Before I turned 65 last year, I began the process to enroll in Parts A and B of Medicare. For reasons I will never understand, Social Security switched my Social Security number to that of my husband, and also started paying me a Social Security spousal benefit that I had never applied for! It was also reduced because I filed prior to age 66!

I followed the advice of the Social Security representatives to whom I have spoken to resolve this, which was to file form SSA-521 (Request for Withdrawal of Application), in which I clearly stated that I wanted to keep Medicare benefits. The end result almost seven months later: I received a letter from Social Security stating that my application for benefits had been withdrawn. This has resulted in a retroactive cancellation of my Medicare Part A coverage and my Part B, as well as cancellation of the Medigap and Part D private insurance plans I later purchased.

Well, I then wrote a letter and took it in to the local office of my U.S. representative, Martha McSally. A congressional inquiry on my behalf finally moved things along. I was advised this morning that my Social Security record has been corrected and my Medicare benefits reinstated under the correct Social Security number. I still have phone calls to make and letters to write to reinstate my Part D drug and Medigap plans, and to sort out my Part B payments.

The moral of my saga is that sometimes contacting your congressional representative does work!