The Medicare Maven on a pricey Rx from a doctor who doesn’t take Medicare

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).

Ale – Texas: My mother was just told that her blood pressure medication will cost more because it was prescribed by a doctor that does not take Medicare. Is this true? I thought it only mattered that the medication was covered.

Phil Moeller: If this is the reason you’re being given, my blood pressure would start to rise as well! Medicare has tightened up on prescriptions written by doctors and other licensed drug prescribers who do not participate in Medicare. But even these drugs should be covered for a short time while your mother seeks a Medicare-approved provider and switches her prescription. But even if this were the case, the cost of the drugs for your mother should not be increased. Odds are that something else is happening within her Part D drug plan. Perhaps the price of this medication was increased for all plan subscribers. Or maybe your mother has entered the Medicare coverage gap (aka the “donut hole”) in her plan, and thus, must shoulder more of the cost herself. In 2015, people enter this gap after total costs for covered drugs paid by the beneficiary and their plan have reached $2,960. Your best bet is to call her Part D plan (or have her call it if you are not registered with the plan as her representative) and find out exactly what is going on. If you are not satisfied with the response, you can appeal to the plan to reconsider the decision, and if you’re still turned down, squawk to Maximus Federal Services, which handles the next level of Part D appeals. You also can call the Texas SHIP office at 1-800-252-9240.

Charles – Wash.: I am a 73-year-old U.S. citizen. I have not worked in the U.S., so I must pay for Medicare parts A and B. I may have to leave the U.S. for a couple of years due to family concerns. If I keep paying these monthly premiums ($407.00 for Part A and $104.90 for Part B), can I return for visits to the U.S. and be covered for medical treatments?

Phil Moeller: Yes, keeping your Medicare coverage active should entitle you to use Medicare when you return to the U.S. You just need to make sure you continue to pay your Medicare premiums. It might help you to get in touch with Social Security before you leave the country and see if there is a foreign address you can give them to make sure you receive any important notices about your Medicare coverage and payment responsibilities. Maintaining your Medicare will also avoid potentially costly late enrollment penalties if you were to return home and decide then that you needed to enroll in Medicare. You may already know this, but paying the premiums for Original Medicare will not give you any insurance for your prescription drugs, which would be covered by a Medicare Part D plan. Your note doesn’t say anything about how you’ve been handling your prescription drug needs, but this could be a factor in your decision. While Part D plans are not mandatory under Medicare, you will face late enrollment penalties when you do sign up for them. These penalties are pegged to the earliest date at which you were required to have Medicare Part B, and at your age the penalties could be substantial.

Uma – Ohio: What sort of penalty is there for signing up for Medicare late? Does it go up every year after the age of 65? To give you more background, my mother became a resident alien in the U.S. at the age of 64 about 5 years ago, and is still not a citizen. Even if she were a citizen she would have to be enrolled in Medicare as someone who never worked in the U.S. and would have to pay over $500 a month, and she has no income. Because she lives with us, she would not be eligible for Medicaid. Companies selling traveler’s insurance would not sell policies to her, because she is a resident alien. No regular full-coverage medical insurance companies will deal with her as she is over 65. So in the meantime, we have a premium reduction, supplemental insurance plan and a dental and vision plan for her at a cost of about $270 a month. If you have any thoughts on a better strategy for this situation for resident aliens and citizens without the history of work in the U.S., it would be very much appreciated.

Phil Moeller: Your mother is in a tough spot, no doubt about it. I am assuming when you say she is a resident alien that she is eligible for Medicare. The agency’s eligibility rules define alien eligibility as follows: “An alien lawfully admitted for permanent residence who has resided continuously in the U.S. for the 5 years prior to the month of enrollment.” If this is the case, she will face stiff late-enrollment penalties, and they could stretch back to when she turned 65. The Part A late enrollment penalty is 10 percent of the monthly premium and will last for twice the number of years she was late in signing up. The Part B penalty also tacks 10 percent onto her monthly premium, but is more burdensome — it’s 10 percent for each year or part of a year she is late in enrolling and lasts for the rest of her life. So if she were five years late, she would pay a 50-percent late enrollment penalty for the rest of her life. Your local Social Security office should be able to give you the official word on how it would calculate these penalties and how much they would be. You also should check to see the earliest date your mother could sign up for Medicare, and if she did so, how long it would take for her insurance to take effect.

In your mother’s case, however, it appears that these penalties would add just more dollars to a Medicare bill that is already way beyond her means, and most likely yours too. I think the big question here is whether the fact that your mother lives with you actually would prevent her from getting Medicaid or other types of help paying her Medicare premiums and insured health care expenses. This is where I’d advise you to focus your efforts. There are Medicare Savings Programs that can pay some or even all of her Medicare costs. There also is Medicare’s Extra Help program that assists with Part D prescription drug expenses. Your note doesn’t mention Part D insurance, but your mother needs this as well, and it comes with its own set of late-enrollment penalties. These support programs, by the way, may be able to waive late enrollment penalties. Call the Ohio SHIP office at 1-800-686-1578 and see what its counselors can do for your mother. Good luck to both of you.

Ginny – Fla.: I signed up for Medicare last year when I turned 65, because I had no insurance. Now my husband may have an opportunity to put me on his employer’s insurance (he is younger than me) at a cost to me that is even less than my Medicare insurance payment. Do I have to continue to have Medicare and pay the $104 a month from my Social Security benefits, or can I cancel Medicare and stop having that money deducted?

Phil Moeller: In most cases, you will not need to keep paying your Part B Medicare premium. The key variable in this case is whether your husband’s group insurance plan will continue as the primary payer for employees or spouses after they’ve turned 65. Most plans do, but if your husband works for an employer with fewer than 20 employers, his play may require Medicare to be the primary payer for plan members who have turned 65. You should ask him to check with his employer. If you decide to withdraw from Medicare Part B, contact your local Social Security office and notify them. They can stop your Part B premiums from being deducted from your Social Security. To do so, they will send you a form to complete and ask you to provide a letter from your husband’s employer stating that his insurance includes drug coverage that is considered “creditable,” meaning it is at least as good as Medicare Part D prescription drug plan. Most employer plans are, but if not, you might be required to keep your Medicare.