Which Medigap plan should you get?

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).

Loren – Md.: I’m 71 and have had Medicare Parts A and B since age 65. I am about to get Medigap — either Plan F or Plan N. Can you explain what the differences are in detail?


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Phil Moeller: Plan F covers more than Plan N and charges a higher premium. Whether the extra benefits are worth it will ultimately depend on your future healthcare needs. Also, because you have had basic Medicare for several years, your rights to get a Medigap plan on favorable terms have long since expired. There generally is a six-month window following the beginning of basic Medicare when people have such “guaranteed access” rights to Medigap. Once that window closes, insurers may choose not to sell you a plan, or if they do, they have the right to charge you higher premiums due to your age and any pre-existing conditions. They can’t do this under guaranteed access rules. Medigap is regulated at the state level, so you should check with the Maryland Insurance Administration to see what your Medigap rights are in your situation. Here’s a list of local SHIP offices in Maryland that might be able to help you.

With that, here are the details you requested.

Both plans cover these items:

Part A coinsurance and hospital costs up to an additional 365 days after Medicare benefits are used up. Paying the 20 percent of covered hospital expenses that Medicare does not pay can be by itself a benefit easily worth your entire Medigap premium. Further, basic Medicare only covers 150 days of hospitalization your entire life. Having an additional 365 days would save all but the wealthiest families from the poor house. Now, it is true that very few people would ever need that much time in a hospital. But having the extra coverage is nonetheless comforting.

Blood (first 3 pints).

Part A hospice care coinsurance or copayment.

Skilled nursing facility care coinsurance. Remember from the last chapter that this coinsurance costs $157.50 from days 21 to 100 (or up to a total of $12,600). Letter plans A and B do not offer this coverage and plans K and L cover only parts of it.

Part A deductible. The 2015 hospital deductible is $1,260.

Foreign travel exchange (up to plan limits). This coverage is for emergencies, not medical tourism or a cleansing ritual at a five-star spa. If you travel outside the U.S. frequently, you should compare Medigap travel coverage against other trip insurance.

Here’s where the coverage of the two plans differs:

Part B coinsurance: Plan F covers these 20-percent coinsurance costs. Plan N covers most of them as well but will charge a $20 copay for doctor visits and up to $50 for emergency room visits that do not result in being admitted to a hospital.

Part B deductible: The annual 2015 Part B deductible is $147. Plan F covers this; Plan N does not.

Part B excess charges: Many doctors and other health care providers charge you more than the Medicare approved rate for their services. Plan F covers these charges; Plan N does not.

Jane – Ala.: Does Medicare cover any parts of a bill for products and labor that go to retrofit your house for independent care after a stroke — showering, preparing meals, maneuvering a wheel chair through widened doorways, ramp building, etc.?

Phil Moeller: Home-based care is clearly on the rise. More and more people are choosing to stay in their homes as they age. However, odds are you’re on the hook for this retrofitting. Medicare generally does not cover anything that is involved with custodial care, which is what you’re describing. It does cover short-term care that has been certified by your doctors as medically necessary. And if you have a medical need for, say, a special kind of bed, you should talk with your care provider and ask Medicare to cover this. As I’ve said frequently, there are exceptions to most if not all of the general statements about Medicare. Even if Medicare will not cover you, there are other programs that might help, including disability resource centers and local aging non-profits. Contact your local SHIP office to see if it can help with contacts. Also, if someone has a low income and qualifies for Medicaid, it offers in-home support services as an alternative to living in a nursing home. Here are details on Alabama’s Medicaid in-home support program.

Bebe – N.C.: I am a clinical social worker who has specialized in working with people with psychotic disorders for more than 20 years. Many of them are disabled and receive Medicare. Sometimes they are dually eligible for Medicare and Medicaid, which can complicate Medicaid payment for services. Medicare, however, does not provide coverage for the enhanced services that many with severe mental illness need to live successfully in the community. Can you give me any information about Medicare coverage of mental health needs?

Phil Moeller: As always, the devil is in the details, and these treatment situations can be very complicated. However, you asked a general question, so I will provide a broad response, courtesy of the Medicare Rights Center. The Medicare Rights Center has a good overview on Medicare’s coverage of mental health services. Pay special attention here not only to what’s covered, but what beneficiaries might have to pay. Mental health providers are the most likely group of any care providers to choose not to accept Medicare’s payment schedule for services. Thus, make sure you understand ahead of time what such visits will cost. Here’s what the Medicare Rights Center has to say:

Original Medicare pays 80 percent of its approved amount for the outpatient mental health services listed below. You or your supplemental insurance is responsible for the remaining 20 percent coinsurance. Medicare Advantage plans must cover the same services as Original Medicare; however, your plan will likely require you to see an in-network mental health care provider. If you have a Medicare Advantage plan, contact your plan to see what your copayments are for seeing an in-network mental health provider.

The services Medicare covers include:

• Individual and group therapy
• Family counseling to help with your treatment
• Tests to make sure you are getting the right care
• Activity therapies, such as art, dance or music therapy
• Occupational therapy
• Training and education (such as training on how to inject a needed medication or education about your condition)
• Substance abuse treatment
• Laboratory tests
• Prescription drugs that you cannot administer yourself, such as injections that a doctor must give you

You can get mental health services in an outpatient hospital program, a doctor’s or therapist’s office or a clinic. Medicare will help pay for outpatient mental health services you receive from:

• general practitioners
• nurse practitioners
• physicians’ assistants
• psychiatrists
• clinical psychologists
• clinical social workers
• clinical nurse specialists

If you see non-medical doctors (such as psychologists or clinical social workers), make sure that these providers are Medicare-certified and take assignment, meaning that they accept Medicare’s approved amount as payment in full. Medicare will only pay for the services of non-medical doctors if they accept Medicare and take assignment (participating providers).

Medicare will pay for the services of medical doctors (such as psychiatrists) who do not take Medicare assignment (non-participating providers), but these doctors can charge you up to 15 percent above Medicare’s approved amount in addition to the Medicare coinsurance. Some states have stricter limits on how much doctors can charge you. Click here for more information on the different types of Medicare providers.

Know that psychiatrists are more likely than any other type of provider to opt-out of Medicare. Be sure to ask any provider if they take Medicare before you begin receiving services. Remember, if you see an opt-out provider, they must have you sign a private contract. The contract states that your doctor does not take Medicare and you must pay the full cost of the service yourself. Medicare will not reimburse you if you see an opt-out provider. If your provider does not have you sign a contract, you are not responsible for the cost of care.
To save money, only use doctors who take assignment.

Annual Preventive Screening for Depression

Medicare covers yearly screenings to detect depression that you receive in doctor’s offices or other primary care settings that can assure appropriate diagnosis, treatment and follow-up. For more information on Medicare’s coverage of the yearly depression screening, please click here.

*Keep in mind that Medicare prescription drug plans (Part D) must cover almost all antidepressant, antipsychotic, and anticonvulsant prescription drugs used to treat mental health conditions.

Lastly, here’s a Medicare Rights Center primer on how Medicare and Medicaid work together.

Note: Ask Phil gets a slew of retiree healthcare questions from people who worked in government and the military. Medicare rules for these folks often differ.

Sharron – Colo.: I am turning 65 this year. My husband is a retired federal employee with Blue Cross Blue Shield coverage. He says that I am covered under his policy and do not need Medicare. Is this true? Do I need Medicare as well as his retiree coverage?

Phil Moeller: The coordination of Federal Employee Health Benefit (FEHB) programs and Medicare benefits is, well, what would you expect from the interaction of two federal programs? It’s tough sledding. The general answer is that your husband is correct. Usually. Maybe. No, seriously, if he has an FEHB HMO (health maintenance plan), Medicare is not required. But it is complicated. I’d suggest you spend time with this explanation of how Medicare and FEHB programs work with one another. Many FEHB programs do require Medicare. So, I’d ask your husband to make sure he’s right by calling his retiree benefits office.

If you or he has at least 40 quarters of work experience at jobs where Social Security payroll taxes paid, you qualify for free Part A hospital insurance from Medicare. This can come in handy, and you should call your local Social Security office (which administers Medicare sign-ups) and get it.

Also, and this may not be trivial, if you do need Medicare, you should enroll soon in Part B to avoid late-enrollment penalties. Part B insures you for covered doctor, outpatient and medical equipment expenses. The late-enrollment penalty can be steep. It is a 10-percent premium surcharge for each year you are late in enrolling. Even if you don’t currently need Medicare Part B now, you should think about whether you might need it in the future, because this penalty is cumulative — 10 percent for each year, for the rest of your life. A key factor in this decision is how your FEHB premiums compare with Part B, and how the two coverages compare. (Such comparisons are easier said than done, I know.)

Dean – Wash.: I am a retired U.S. Navy veteran. My wife and I have Tricare medical. I am 57, and my wife is about to turn 65. She already receives Social Security. What are our options as far as Medicare? Do we have to enroll in it and pay the premiums? Or can we just use the Tricare?

Phil Moeller: Your wife will have to get Parts A and B and pay required premiums to participate in the Tricare for Life program. She will need to work with Tricare to make this transition. However, on the upside, Tricare charges no premiums itself. And it offers prescription drug coverage, so she should not need a Part D Medicare drug plan. Lastly, basic Medicare can be used anywhere in the country.

Christina – Ariz.: I am still working and don’t plan to retire until I’m 70. I signed up for Part A Medicare but will not use it until I quit. I am covered by my employer’s health plan as my primary, but when I turned 65 two months ago, Tricare told me that the only way I could use them to help cover my co-pays for medications was if I used Medicare Part D for medications! I’m about to run out of some of my meds and have relied on the military to help me pay for them. Now what? I’ve called several people at Tricare and one tells me, “You’re fine,” while another says I have to now use Medicare. I am getting a different answer from each person I ask. Do I have to buy Medicare Part D at a cost of $150 a month in order to have it cover what Tricare used to cover? I didn’t think you could use any part of Medicare if you were still working? Help, please.

Phil Moeller: As my answer to Dean stated, Tricare generally provides its own prescription drug coverage so you shouldn’t need a Part D plan. Check these Tricare pharmacy eligibility rules to make sure. You should call Tricare again and refer them to these rules in case you get someone on the phone who says you must get a Part D plan.

Mary – Va.: I am 72 years old and have full coverage with Medicare/Tricare. I have a medical need for intermittent home health care for a few days a year when I am disabled with Meniere’s disease. Is there any coverage at all with Medicare for this need? I am a low-income senior, and Tricare will only pay secondary to Medicare. So if Medicare doesn’t cover it, Tricare will not kick in.

Phil Moeller: Medicare does provide short-term care in your home so long as it’s medically necessary. The care needs to be skilled and medical in nature and not what’s called custodial care — for meals, housekeeping and the like. Work with your doctor’s office on this, and make sure any care provider you use is approved by Medicare and has agreed to its rates for the services you need. Medicare usually pays only 80 percent of care costs, but your Tricare coverage should pick up the rest. If it doesn’t, there are support programs for low-income beneficiaries. Call your local SHIP office if you need additional help.