Your Medicare tax dollars at work

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.

Karen – Wash.: You can call this story “Your Tax Dollars at Work.” I recently had a hospitalization due to my cystic fibrosis, as I usually do every couple of years. I usually spend a few days there, and then go home to do a few weeks on IV antibiotics using home health care. This was my first hospitalization on Medicare. When it came time to set up my home health care, I learned that Medicare doesn’t cover home health care for IV antibiotics, and if Medicare doesn’t pay for it, then my secondary insurance won’t either. But good news! Medicare will pay for me to stay two weeks in a nursing facility for someone to hook up my IV twice a day. I have been doing this at home for the past 20 years with IV antibiotics in small, portable bags, so I could even go to work! Now that I’m 65, I apparently have to be in a “skilled nursing facility” and isolated in a room! Yep. A nursing home. For two weeks. I got a physical therapist, an occupational therapist, a nutritionist, a social worker, a nurse, a doctor, three meals a day, plus I took up a bed for someone who needed it. (I didn’t go to the Bingo games or sing-alongs.) I lasted three days and then escaped, agreeing to pay out of pocket for my own health care. How does this make any sense at all?

Philip Moeller: Karen is who Donald Trump should be thinking about if he really wants to make America great again. Unfortunately, Karen’s “welcome to Medicare” moment is probably an accurate retelling of the program’s complex coverage rules. According to the Medicare Rights Center, which provides free Medicare advice to consumers, “This service falls between gaps in Medicare coverage. If the medication is infused with a pump, the medication and pump can be covered under Part B, but there is no coverage of nurses to set it up. If the medication is not used with a pump, it is covered under Part D, and only the medication, not the supplies, are required to be covered, but some Part D plans will cover the supplies.”

If Karen were homebound, Medicare would cover her. But, bless her heart, Karen is out there dealing with her illness and living her life. So, she is not covered. This is silly.

Dan – Va.: I am 54 and on disability. Do I have to have Medicare? Can I just buy a health care policy on the open market or my state Obamacare exchange?

Phil Moeller: This sounds logical, but according to the good folks at the State Health Insurance Assistance Program (SHIP), Dan can’t do what he suggests. This assumes that he does not have health coverage through a spouse’s employer health plan. If not, and given that he is eligible for Medicare due to his disability, Medicare will always be the primary insurer, and so he needs to get it. Otherwise, even a terrific private plan will only be able to be a secondary insurer after Medicare, and Dan would have no primary health insurance coverage.

Wunphen – Thailand: I have lived and worked in the U.S. for almost 40 years, but I’m currently living in Thailand. I return to the U.S. periodically. I am 65 and have applied for Medicare Part A, but was informed that I cannot qualify for Medicare, because I did not live in any of the 50 states at the time I applied for Medicare. I am very confused about this, because I have read somewhere that American citizens living abroad who qualify for Social Security also qualify for Medicare Part A.

Phil Moeller: Wunphen is right to be confused, not to mention entitled to be irked. U.S. citizens are eligible for Medicare. If they have enough earnings from jobs at which they paid Social Security payroll taxes, they will have to pay no premiums for Part A, which covers stays in hospitals, skilled nursing facilities and other qualifying health care facilities. Even if he did not qualify for Social Security, Wunphen would still qualify for Medicare, although he’d have to pay steep premiums for Part A. He can get Medicare enrollment forms from the U.S. embassy in Thailand, or if more convenient, from U.S. consulate offices there. “The Social Security Administration should also mail you a letter notifying you that your Initial Enrollment Period has begun, along with a form to request an enrollment packet,” according to the Medicare Rights Center. “Be sure to keep copies of any forms that you complete and to mail them with the ability to track their delivery.”

Miles – Panama: I am 68 years old and currently collecting Social Security. I am a permanent resident of Panama (the country). I am currently paying for Medicare. I have been told that expats will not have to pay a penalty for cancelling Medicare and then reapplying at some future date. Is this correct?

Phil Moeller: Most likely, Miles is not correct, according to a spokesman for Medicare. This assumes that he is not a military or government employee, or that he is not volunteering and getting other health coverage from a non-profit agency in Panama. Assuming he does not meet one of these qualifying exceptions, he would get hit with late-enrollment penalties should he cancel his Medicare and resume it at some later date. A key determinant here would be how long Miles stays in Panama. For example, if he goes without Medicare for a dozen years and then moves back to the states at age 80, any penalties he faces might be an acceptable price for not paying Medicare premiums all those years. And at 80, he might not have all that many years of life left.

Paul – Ohio: I just turned 66 and work at a small, stand-alone theological school. In a faculty meeting last week, the academic dean suggested that those of us over 65 and still working full time drop the health insurance provided by the school and go on Medicare to help the school’s financial situation. I would appreciate any advice you can offer about the advantages and disadvantages of taking the dean’s suggestion. I am planning to work until I am 70 in order to maximize my Social Security benefits.

Phil Moeller: Your employer most likely cannot force you to take Medicare rather than continue participating in your group health plan. Some employer plans can do this, but only if they include 20 or fewer participants. If your plan has more members, and I’m assuming it does, then you cannot be required to get Medicare.

That’s the rule, but your question goes beyond this. If you are sympathetic to your school’s financial situation, you are certainly free to leave its plan and get Medicare, even if it costs you more money than you’re currently paying. Of course, if your wife is covered on your plan, she will have to either get Medicare herself, or if she has not yet turned 65, she will have to seek private health insurance, most likely on your state exchange set up under the Affordable Care Act. If you have any children (up to age 26) covered on your plan, you’d also need to get coverage for them.

If you voluntarily leave your employer plan, you will have an eight-month window to enroll in Medicare. I strongly suggest you work with your benefits administrator to make sure you do not unintentionally encounter a break in your health insurance coverage. In other words, even though you may have eight months to get Medicare, you should do so as soon as possible to make sure you maintain your coverage.

There are, of course, different kinds of Medicare policies. The best choices for you are way beyond the scope of this answer. However, for starters, you would need to decide between the coverage paths of Original Medicare — Parts A and B, possibly a Medigap policy and a Part D prescription drug plan — and Medicare Advantage. Medicare Advantage can include most if not all of the first path’s coverage plus some additional choices. However, its provisions can differ from those of Original Medicare, and thus, you will need to do additional research. One place to begin would be to look at the headlines of some of the columns I have written and see if some items there are helpful. Some of the pieces I wrote last October and November about Medicare’s annual open enrollment period may provide you a useful primer about your coverage choices.