Thanks, but no thanks, Medicare, for the love

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). It is funded by the government but is otherwise independent and trains volunteers to provide consumer Medicare counseling in state and local offices around the country. The non-profit Medicare Rights Center is also providing on-going help.

Moeller is a research fellow at the Center on Aging & Work at Boston College and co-author of “How to Live to 100.” Follow him on Twitter @PhilMoeller or e-mail him at medicarephil@gmail.com.

Denise – Ohio: Has anyone ever looked into the wasteful expenditures of health insurance providers? I have a Humana Medicare Advantage Plan and continuously receive brochures and packets of information on how to track my medications (I take one medication per day), exercise and diet plans, etc. I even received a Christmas card from them. Really?

I’ve also received phone calls asking me if I’ve had certain “covered” tests done, and if not, when I plan to schedule them. They’ve also asked if my doctor spoke to me about “falling.” Do I really wish to squeal on my own doctor? I realize some of the excessiveness may be required by federal law(s), but I’m not alone in my feelings of being “smothered” by these people. It’s nice to be loved, but it’s been my experience that when you truly need them their only concern is their “bottom line” of costs.

Perhaps if they wouldn’t squander their funds on unnecessary paperwork and TV advertisements they might just have enough to pay the costs that actually are required during illnesses and beneficial to their insured.

Phil Moeller: Ooh, don’t forget birthday greetings, too! Lots of think tanks and news organizations have done extensive studies and reports on health insurance waste, fraud, and “legal” overcharges involving Medicare and the Medicare Advantage plans provided by private insurers. Indeed, you can enjoy hours of socially outraged enjoyment just by loading your favorite search engine with phrases like “Medicare fraud” or “Medicare Advantage overcharges.” The results will take you a long time to read, although perhaps not as long as waiting for your health insurer to pay an insurance claim! Ha ha! Here’s an on-point report from the Center for Public Integrity on Medicare Advantage overcharges that are so large they can pay for all the feel-good communications in the world with profits left to burn.

If you didn’t already know this, the rates charged by Medicare Advantage plans must be approved every year by Medicare, according to complicated rules created by Medicare. Plan communications are overseen by, you guessed it, Medicare, and must contain specific information requirements stipulated by . . . Medicare. Are you seeing a pattern here?

It would be comforting but naïve to think that tougher and more transparent Medicare oversight could make these excesses go away. Companies that are in regulated industries develop effective ways to circumvent the intent of their overseers and optimize profits however they can. If you change the rules, they will adapt. That’s what they do. Expecting them to do otherwise is unrealistic, if not silly, as behavioral economists and others have documented.

Russell – Calif.: I’m 61, on disability, and have original Medicare. Can I enroll in a Medicare Advantage plan any time, or only during open enrollment?

Phil Moeller: In most situations, you are restricted to open enrollment each fall, which is from Oct. 15 to Dec. 7. However, if you have experienced a life-changing event, such as moving to a place where your current insurance plan is not offered, then you qualify for a Special Enrollment Period. There are lots of qualifying events, so look carefully at this list.

Lastly, you can sign up for Medicare Advantage anytime during the year (but only once during a year) if you are purchasing a plan that has received Medicare’s top five-star rating. There are only a handful of such plans with five-star ratings for 2015. But the largest is a Kaiser Foundation plan offered in 31 California counties. If you live in one of these counties, you may be in luck.

Kathleen – Ohio: When my mother turned 65, she was still working and planned to continue for a few more years. A Medicare official told her since she had insurance she was happy with, she had no need to sign up for Medicare. But when she submitted her first claim after her 65th birthday, her insurance company paid only 16 percent of it — 80 percent of the 20 percent Medicare wouldn’t have covered. Without her knowledge (and without lowering her premiums), they had switched her to a Medicare supplement policy.

The insurance company told her it was their standard policy to consider themselves secondary insurance for anyone eligible for Medicare, whether they had signed up for it or not. Granted, this was many years ago. But did the Affordable Care Act specifically outlaw this practice? Do people really have a choice about using Medicare or not?

Phil Moeller: Your mother was probably working for a small employer with fewer than 20 employees. Under amendments to the federal Medicare law dating to the 1980s and unchanged by the Affordable Care Act, group health plans through small employers pay secondary to Medicare (i.e., Medicare pays first). If a person who is eligible for Medicare and covered through a small employer doesn’t sign up for Medicare Parts A (hospital) and Part B (medical), then they don’t have primary health insurance coverage.

You say her employer had switched her to a Medicare supplement policy. I find this hard to believe. First, the premiums for Medigap policies can be steep and doubtless would have changed her insurance payments. Second, her employer can’t unilaterally switch her into a supplement plan. Third, assuming they unintentionally approved a Medigap policy, she would have had to be enrolled in Medicare because a person can’t qualify for a Medigap policy unless they have Parts A and B of Medicare. Fourth, and most telling, if she had been switched into such a plan, she would not have been saddled with such a steep bill.