Medicare failures cause open enrollment hassles

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.

Linda – Colo.: This is INSANE!  Whoever came up with this Medicare Rx plan was just a crazy person who cannot think straight. When I’m on the website, I can only compare three plans at any one time, but I get a total list of 28 plans available to me in the state of Colorado. None of them tell me what the copays will be for 2016 nor do they have the formulary easily available. So far, I’ve gotten two sets of comparisons, but this is still not enough to make an informed decision. During open enrollment each year, I spend hours and hours of time trying to find a plan that I can afford along with the meds that I need. But I am not a seer and have no way to divine what ailments I might have during the entire year of 2016!  This is just insane, and I know it’s hopeless to complain, but this year I felt that I must. I’m just 69 and still have my faculties. What in the world do older folks do who don’t have their senses anymore?  Not that any aspect of the plan makes sense anyway.  I guess it’s just designed to get most people to just stick with one plan, pay through the nose and get every last dollar squeezed out of us senior folks.

Phil Moeller: There’s not much I can add to what Linda says. I share her experiences in the hope that it will be seen by the folks who oversee Medicare at the Centers for Medicare & Medicaid Services. Medicare’s Plan Finder will allow Linda to enter all the prescription drugs she now takes, see if they’re in the formularies of Colorado drug plans and get a rough idea of how much they will cost her. But when I did this for my ZIP code using the prescription drugs I take, I still got a list with far, far too many plans to compare. And as Linda notes, Plan Finder tells you little about the drugs you are not taking. In its defense, there are a zillion drugs, so expecting Plan Finder to tell you about all of the drugs you might take doesn’t make sense (at least to me). But it would be great if Plan Finder included links to plan formularies so folks like Linda can more easily find out which meds are covered by which plans. I would advise Linda to do the best she can based on plan costs using her current drugs. I’d look at maximum out-of-pocket costs for the plans plus the convenience of the plans’ available pharmacies. Linda can enter her preferred pharmacies as part of the plan screening process, so perhaps this will help weed out plans that don’t make sense for her. Rather than stick with the same plan, she and others should purchase whatever plan in 2016 offers the best combination of cost and pharmacy convenience. Limiting the search to plans rated highly by Medicare, using its one to five star ratings system, may further narrow the list. And as Linda knows, this is only a one-year decision. If she is not happy with her choice, she gets to pick a new plan next year.

Lois – N.Y.: I’d like to know if there are any Medicare consequences to travelling abroad for three months if I am maintaining a residence in the U.S. I am enrolled in a Medicare Advantage plan. The second question is trickier. If I apply for residency status in Ecuador (and still maintain my apartment in New York), I will need to be in Ecuador for nine months for each of two consecutive years. If I maintain a residence in New York, can I still maintain my Medicare Advantage plan? Is there a set amount of days or months I can spend out of the country before I lose my Part D prescription plan? And lastly, could I switch gears and get a Medigap policy and maintain that?

Phil Moeller: You can keep your Medicare plans so long as your premiums are paid and up to date. You then can use this coverage when you are back in the U.S. Maintaining it will also allow you to avoid penalties later on when you are back in the U.S. full-time. Anything more than a 63-day break in Part D coverage can trigger lifetime penalties imposed when you once again sign up for a drug plan. As you may know, basic Medicare (Parts A and B) does not cover you outside of the U.S. Some Medicare Advantage plans do provide emergency coverage for foreign travel, so you should check with your current plan to see whether it will be of any use here. If not, you might want to shop for a new Medicare Advantage plan during this year’s open enrollment season, which ends Dec. 7. Some Medigap policies do provide non-U.S. coverage. Here’s a link to Medicare’s Medigap guide. Check out page 11 for details on which plans include coverage for foreign travel emergencies. Because you will not really be traveling outside the U.S., but living in Ecuador, I’d make sure you understand the rules of what qualifies as emergency coverage. To be really safe, you might want to explore health insurance policies in Ecuador. Good luck, and safe travels!

Anonymous – N.Y.: I have had 25 physical therapy claims and reached Medicare’s cap for 2015. I do have secondary insurance through a private health policy that will allow me up to 15 additional covered sessions. But they tell me they are unable to process the claims, because the Medicare Summary Notice shows zero patient responsibility under “Notes for Claims Above,” and if there is no obligation to pay, they say there is nothing for them to cover. Medicare tells me to send in an appeal, but that won’t work, because I’m not appealing their denial, just the fact that they are saying I don’t have to pay. How do I get the Medicare Summary changed? Who administers Medicare anyway?

Phil Moeller: Medicare hires firms around the country to manage Parts A and B of Medicare. They’re called Medicare Administrative Contractors, or MACs, and as far as I can tell, they keep as low a profile as possible and are one of the best-kept secrets of the program. They are the ones you need to talk to. Here’s a map of all the Medicare Administrative Contractors that includes contact information. Other than that, you seem to have a good plan to get the Medicare Summary changed. Good luck, and please let me know how things turn out.

Lynn – Calif.: I’m 60 (turning 61 in January 2016), and my husband is 64 (turning 65 in October 2016). We both work full-time, and we have health insurance coverage through my employer (with 150 employees). Does my husband have to go on Medicare when he turns 65, or can he remain covered by my health plan?

Phil Moeller: Lynn poses one of the most frequently asked questions I get. Until everyone on the planet reads and memorizes every installment of Ask Phil (the Maven is not holding his breath until this happens), I will continue to address such common issues. Your husband does not have to go on Medicare when he turns 65. If a person is an active participant in an employer group health plan, and the employer has more than 20 employees, there is no requirement for either the person or their spouse to sign up for Medicare at age 65 or 75 or 85 or, well, you get the point. “Active” is an important modifier here. It means that the person with the group insurance is still an active employee of the organization where he or she is insured.

Susan – Md.: I am 63 and plan on working until at least 66. Realistically, I should work until I die, but the commute is killing me. Anyways, my hubby is retired, and we are both now on my medical plan. This year my employer has switched to the handy dandy PPO/HSA [preferred provider organization/health savings account] plan and will pitch in part of the deductible.  My hubby is on Medicare Part A only. We were told he had to take it by our local senior citizen center. What will happen when I turn 65, as apparently you cannot use a health savings account if you are taking Part A or B? The insurer told me to decline both Parts A and B and tell Medicare I am an active full-time employee. Is that the correct information? I thought you were forced to take Part A or were penalized later on.

Phil Moeller: I am still trying to wrap my head around the notion of someone who wants to work until they die, but is being killed by the commute! What a logical strategy!

I also want to preserve this answer for all those times when insurance companies say I never take their side: Susan, your insurance company is correct! I assume your husband is taking Social Security. Otherwise, I don’t know why the senior center said he had to take Part A. It’s true that Part A can be a helpful secondary payer for some insured hospital expenses that are not paid by your employer health plan. But there is no requirement that someone take Part A unless they are receiving Social Security in which case you must take Part A. If you’re not taking Social Security yourself, you do not have to take Part B even if you’re 65 or older, so long as you’re covered by an employer group health plan, which you are. So you’re fine. You should be able to stay in your health savings account. However, because your husband is taking Part A, he will not be able to make a contribution to the health savings account, including the $1,000 age-related “catch up” contribution. You will, however, be able to make the maximum contribution to the plan, including your employer’s payment. If you get a Medicare card from Social Security when you turn 65, just send it back and reject the coverage. I’d also advise calling Social Security to make sure the agency does not mistakenly keep you enrolled.

Tamara – S.C.: My parents, who are 69 years old, just sold their house in Pennsylvania and moved to Florida. They need to find new health insurance. In Pennsylvania, their Medicare was the secondary insurance. Now that they are in Florida, it looks like Medicare will become their primary. Do you have any suggestions on where they should begin shopping for insurance?  I recommended they go to the closest Social Security office and start there. They will need a health insurance plan that covers them out of state in case they travel to visit family in Virginia and South Carolina. They are also concerned about what health plan to get for my disabled brother who is 47 years old and will be living with them. He receives Supplemental Security Income (he was born with cerebral palsy and is severely cognitively impaired).  I was hoping they could find a plan for him that would continue if and when something happens to my parents (his primary caregivers).  He most likely would then have to come live with me in South Carolina.

Phil Moeller: Social Security is NOT the place to call for Medicare coverage tips. The agency processes some Medicare eligibility, enrollment and premium payments. But it has nothing to do with the actual Medicare health plans available to your parents. As for their specific situation, I would need to know more about why their move from Pennsylvania to Florida changed their Medicare from secondary to primary. Perhaps one of them retired and lost access to employer group coverage? But if they already were retired, unless they worked for the federal government, all employer retiree plans already pay secondary to Medicare. So I am puzzled. Also, as you may know, each of your parents will need their own Medicare coverage, as Medicare covers only individuals and not families. From your description of your brother, he may be eligible for Medicaid insurance coverage if he is not already receiving it. Your best bet is to get help with Medicare and Medicaid possibilities for your parents and your brother from the Florida office of the State Health Insurance Assistance Program. Ask to speak with a trained Medicare counselor. This is a free service. Before calling, you should gather details about your parents’ existing Medicare coverage and family income information that might be needed for any Medicaid application. Good luck.