Editor’s Note: Journalist Philip Moeller, who writes widely on health and retirement, is here to provide the Medicare answers you need in “Ask Phil, the Medicare Maven.” Send your questions to Phil.
Medicare rules and private insurance plans can affect people differently depending on where they live. To make sure the answers here are as accurate as possible, Phil is working with the State Health Insurance Assistance Program (SHIP) and the Medicare Rights Center (MRC).
Judy – Fla.: We currently have a Medicare Advantage policy. Michigan is our primary residence. While in Florida last winter I had shingles. I was covered by insurance for visits to urgent care clinics but was informed I really needed to see a physician for ongoing treatment due to the severity of the shingles. I also receive light treatments for psoriasis while in Michigan. My policy has no participating physicians in Florida to cover either of these situations. Can I use only Medicare to cover these situations, and if so, how do I accomplish that? I understand I can buy a policy that covers me outside my policy area, but Medicare is a national program. Is there a way to use just basic Medicare since I pay for that coverage each month?
Phil Moeller: Original Medicare is national, but Medicare Advantage plans are not. Most cover you for services in their local network but not for health care needed when you travel outside it. If you are going to be in Florida regularly or elsewhere outside Michigan, your best bet is to drop your Medicare Advantage plan during this year’s Medicare open enrollment period, which will begin Oct. 15 and extend through Dec. 7. See if there’s a Medicare Advantage plan in your ZIP that offers out-of-network coverage that works for you. If not, Original Medicare is your best bet.
If you enroll in a stand-alone Part D plan, your Medicare Advantage plan should automatically end, and you will be enrolled in Original Medicare, which includes Part A for hospital services and Part B for doctors, outpatient services and medical equipment. These are the same things covered by your Medicare Advantage plan, although it might also have covered some other things beyond Original Medicare. Once you have Original Medicare, it will cover you anywhere in the U.S., and you are free to use any doctors or health providers who participate in Medicare (and nearly all do). When you get Original Medicare, you also should consider getting a Medigap plan to cover Medicare copayments and other things that Original Medicare does not cover. There are 10 to 11 different Medigap plans available to most people. Medicare has an online Medigap plan finder that should help you. You also can call a Michigan SHIP counselor at 1-800-803-7174 to help you better understand your Medigap options.
Chris – Tex.: I participate in a high deductible health plan (HDHP) at a Fortune 500 company that allows me to also participate in a health savings account (HSA). The HSA currently allows me to save $4,350 annually, pre-tax, which can grow in my HSA account and be withdrawn tax-free any time in the future as long as the funds are used for medical expenses. This includes long-term care. If you can let the funds sit and grow, it’s a good thing. However, when you turn 65, you can no longer participate in an HSA when you have Medicare. I don’t want to do that. But I also hope to work for this Fortune 500 company and be covered by their HDHP medical coverage for a few years past age 65 and would like to still contribute to an HSA account for those extra three or so years. What do I need to do with Medicare so as to NOT incur a penalty for signing up “late” (past age 65) yet still be eligible to participate in the HSA? Or is it really not doable to do both?
Phil Moeller: HSAs can be a great health and retirement tool. You can save and invest the balances tax-free and not be taxed when they’re spent, either, so long as it’s on eligible health care items.
As for continuing in your HSA past age 65, you should be fine. You do not need to sign up for Medicare so long as you have group health coverage and are an active employee. Your employer needs to have at least 20 employees as well, but you did say you were with a big company, so this is not an issue for you.
As an extra precaution, get in touch with your benefits folks at work and make sure your health plan’s drug coverage is what’s called “creditable” — meaning it’s as good as Medicare. I’m sure your employer plan is, but better safe than sorry. If it wasn’t, you might need to sign up for Medicare.
Also, signing up for Social Security automatically signs you up for at least Part A of Medicare. Even though this is free to most folks, it can make you ineligible for continued participation in the HSA.
William – Fla.: I am currently covered under my wife’s insurance through her work at a very large company. I just turned 65. Do you know if I will be required to take Medicare as my primary coverage, and then does my wife’s insurance becomes the secondary? Or can I just stay on her policy and opt out of Medicare until she retires? I get a monthly check from Social Security, and they have already begun withholding $104 from my check. Does that mean I am already in the Medicare A program, and would you recommend I keep that and use my wife’s coverage as the gap coverage?
Phil Moeller: That $104 is for the Part B premium, and while it’s nice of the good people at Social Security to automatically sign you up, you shouldn’t need to get Medicare or pay the Part B premium. There is a small chance your wife’s employer might want her insurance to become what’s called a secondary payer when you turned 65. That’s unusual but you should ask her to find out. But if her plan is still the primary payer for you, you should call Social Security, explain that you do not require or want Part B coverage and find out how to get your money back and stop premiums from being withheld from your Social Security payments. As was the case with Chris, you should make sure your wife’s coverage is creditable before disenrolling from Part B.
Jeff – Fla.: My mother is 91, has dementia and is in a Medicare Advantage plan. She has recently moved from her apartment to a memory care assisted living facility. However, there is only one plan doctor who visits the facility, so we would need to transport her to other doctors as needed. If we switch to Original Medicare, there are other specialists who will treat her at the facility. Can we switch her? Do we need to wait until open enrollment period? What additional costs might we entail?
Phil Moeller: There are different ways this could go. The easiest solution would be to find another Medicare Advantage plan with the types and numbers of doctors you need to visit her where she now lives. Moving to a new residence is one of the events that can trigger a special enrollment period that would allow her to make such a shift immediately. Such a move is most easily accepted as a cause for switching insurers if the move takes you outside the plan’s service area. This does not appear to be the case here. But moving into a specialized care facility can be a qualifying event for changing Medicare coverage right away. I’d call a SHIP counselor in Florida at 1-800-963-5337 and see if they think you can make this case.
Otherwise, you will have to wait to shift plans until this year’s Medicare open enrollment period, which begins Oct. 15 and extends through Dec. 7. You could switch to another Medicare Advantage plan effective next Jan. 1. Or you could sign up for Original Medicare as you suggest. Odds are your costs will go up. Your mother’s drug coverage most likely was included in her Medicare Advantage plan. You will need to get a stand-alone Part D drug plan. And you should seriously consider getting a Medigap policy for your mother. However, because of her age and health condition, finding the right Medigap policy at the right price may be tough. Check out the links I provided above to Judy. Again, SHIP might be able to help here.
R.J. – Md.: I was recently told by hospice that Medicare will no longer pay for Lewy Body Dementia hospice care. A quick check on the LBD caregiver blog found that a rumor is going around that Medicare is no longer paying hospice for Dementia patients. Is this true?
Phil Moeller: No. LBD, which is the second leading cause of dementia after Alzheimer’s disease, is a covered condition under Medicare hospice benefits. The key, as with all hospice care, is that patient eligibility requires a doctor’s prognosis that death is imminent, which is usually defined as meaning within six months. If the person lives longer than six months, a doctor must recertify eligibility for hospice care. Hospice eligibility can be tricky, so you also may want to call Maryland SHIP at 1-800-243-3425 for help.
My mind took an unauthorized vacation recently when I answered Judy about shopping for Medicare. She wanted to know the cost of Original Medicare if she also purchased a Medigap policy. My answer quoted her a price for a Medigap plan F policy. However, I said she also needed to pay annual deductibles for Original Medicare’s Part A hospital coverage and Part B coverage of doctor, outpatient, and medical equipment expenses. Plan F Medigap policies, of course, also cover these deductibles.