Ep 5. - Navigating the Medicare Maze
Planning for retirement involves navigating the complexities of Medicare sign-up, a process that can be confusing and lead to regrettable mistakes. Join hosts John Bever and Jim Uren as they break down key decisions, such as choosing between traditional Medicare and Medicare Advantage, understanding when to sign up, and avoiding enrollment penalties. They'll also address the need for separate prescription drug coverage and provide valuable insights to help you make informed choices. Tune in to gain essential knowledge, recognize pitfalls, and successfully navigate the Medicare maze with confidence.
In this episode, you will be able to:
- Understand the differences between Medicare Parts A, B, C & D
- Explore the pros and cons of Medicare Advantage plans
- Discover your Medicare eligibility requirements
- Avoid common Medicare enrollment mistakes and penalties
- Learn where to get free resources to help you make better informed Medicare decisions
The key moments in this episode are:
00:00:05 - Introduction to Retirement Planning and Medicare
00:00:45 - Understanding Medicare Coverage
00:03:27 - Options for Senior Health Insurance
00:10:41 - When to Sign Up for Medicare
00:14:16 - Steps for Signing Up for Medicare
00:15:29 - Choosing Medicare Coverage
00:19:08 - Pitfalls and Traps of Medicare
00:22:17 - Part D Coverage and Open Enrollment
00:24:27 - Long-Term Care Costs and Coverage
00:26:34 - Navigating Medicare Enrollment
00:30:38 - Thankfulness Shared by Hosts
00:31:18 – Podcast Disclaimer
Discussed on this Episode
Medicare Website: https://www.medicare.gov/
“Who Pays for Long-Term Services and Support?” from the Congressional Budget Office: https://crsreports.congress.gov/product/pdf/IF/IF10343
2022 Medicare Trustees Report: https://www.cms.gov/files/document/2022-medicare-trustees-report.pdf
Resources:
Will I be Enrolled Automatically in Medicare?
Will I Avoid Medicare Enrollment Penalties?
Will I Avoid IRMAA Surcharges on Medicare Parts B and Part D?
Transcript
Jim Uren: This is The Year You Retire podcast for people who want their first year of retirement to be right on the money. Your hosts are me, Jim Uren and John Bever, CERTIFIED FINANCIAL PLANNER™ professionals with Phase 3 Advisory Services. Retirement is one of the happiest times of life, but getting the most out of it requires you to be properly prepared.
Listen along as we explore the financial topics, tips, and strategies that will help you make your first year of retirement your best year yet. Now let's get planning.
Today's episode is navigating the Medicare maze.
This podcast focuses on persons 65 and older, or soon to be, who want to answer the following questions:
- What are my options for senior health insurance coverage?
- What are the steps to signing up for Medicare?
- What are the pitfalls and potential traps that I should be watching out for?
Now, the most important thing, if you want to get more familiar with Medicare is to visit medicare. gov. Be careful of other sites because there's a lot of bad information out there. But in this podcast, we’re going to be covering only retiree Medicare. We're not talking about disability Medicare. So it's important to make that distinction.
John Bever: So here's the first question. When was Medicare started?
Jim Uren: That is a good question. I believe it was under the Johnson administration, but I don't remember the year.
John Bever: You got it, July 30th, 1965, and that was 20 years though after Harry Truman proposed it. So it took a little while to get through.
Jim Uren: And that's 30 years after Social Security.
John Bever: That's correct.
Jim Uren: So that's interesting. That's interesting.
John Bever: And so our listeners can find out about that by listening to our podcast on Social Security.
Jim Uren: That's right. And so, John, who does Medicare actually cover then?
John Bever: Well, it's interesting. Most people think it covers just those 65 and older, but it also covers those that are in another program with health insurance for people that have limited income that's funded by state and federal sources.
So it's actually possible that some people may be covered by both Medicare and Medicaid. So if someone is eligible for Social Security disability benefits, they're also eligible for Medicare after a 24 month qualifying period. But this, this podcast is focusing on the retiree coverage and we need to cover a couple of clarifications here that are very important.
So with Medicare, we are talking about doctor coverage, drug coverage, hospitalization coverage. Medicare does not cover, for the most part, does not cover long term care services. So it's not designed for care needs such as nursing home, cognitive, in home, or adult daycare. And a lot of people think that that is covered under Medicare, and it is not.
But it does cover most hospice and palliative care, which oftentimes comes along with that end of life care. So there are very limited benefits for nursing and rehab care. We'll talk a little bit about that later in the podcast.
Jim Uren: Yes, and that can't be emphasized enough that Medicare is not a long term care solution. So you need to come up with other options. That's very, very important.
So, John, what are the options that we have available through Medicare for senior health care?
John Bever: Okay, so let's talk about original Medicare first, and then we'll get into extra private health insurance that you may need.
So, Medicare comes with two parts. Part A, which is your hospital, hospice, and minimal skilled nursing care. Generally, most people will not pay for it, but it does have a $1,600 deductible for every time you are in the hospital. Each hospital stay is different. It's not an annual deductible, very different than most health insurance that people have.
Part B is your doctor, outpatient, your supplies, your preventative services. And in 2023, the premium for that is $164.90, and that premium generally does increase every year. In 2023, it did decrease, but generally it increases. And it is a progressive premium, which means the more you make, the more you may pay. There is a deductible on Part B, and that deductible is $226.
So, when you are on Medicare, there are several options available to enhance your coverage or to address specific health care needs. So, these options include a Medicare supplement insurance, often called MedSup, or called Medigap. There is Medicare Advantage, which is also called Medicare Part C. (So we're getting into the alphabet soup here.) And there are healthcare sharing ministries that are oftentimes referred to as HCMs.
So after you sign up for Original Medicare, you have a choice of, do I want to add a Medicare supplement insurance? Or do I want to go to Medicare Advantage Part C, which is all inclusive? Or do I want to add in healthcare sharing ministries or HCMs?
You can only have one of those in addition to your original Medicare. But, in addition to that, you also need Medicare Part D, which is the prescription drug coverage. And lastly, there are certain situations with Medicare that there are special needs plans. These are called SNPs. They are specialized Medicare Advantage plans designed to meet the specific needs of individuals that have certain chronic conditions or institutional residency, so we will not be covering that today. And lastly, there are those programs for low income individuals. We are focusing on Medicare Part A and B, which is original Medicare, and then what you need to have on top of that.
So let's go back to Medicare Supplement Insurance, or Medicare Supplement, MedSupp, Medigap, those are the different terms that are used. These are offered by private insurance companies, and they can help cover some of the out of pocket costs, such as the deductibles. And there is that deductible on Part A. There is a deductible on Part B.
So, to enroll in a MedSupp plan, you need to have Medicare Part A and Medicare Part B. You get that by going to the Social Security website and signing up there. And it is important to note that Medigap plans cannot be combined with Medicare Advantage plans. Medicare Advantage plans are different. So if you take original Medicare Part A and B, then you will sign up for a Medicare supplement or Medigap plan or possibly a healthcare sharing ministry.
However, some people choose to go with Medicare Advantage. Medicare Advantage is also called Part C, and it is an all-inclusive ABC altogether. Medicare Advantage plans are offered by private insurance companies once again, and they do provide an alternative. These plans include all the benefits of Part A and B and sometimes some additional benefits. Sometimes it will include prescription drug coverage, which is part D, (and we're back to the alphabet soup). But can also sometimes include dental, and vision, and hearing coverage, and maybe even, in some cases, health club memberships.
There are restrictions, however, with Medicare Advantage plans, and typically you have network restrictions, so you don't have the choice of any doctor that you want to go to. And this can be especially difficult for snowbirds, those who travel a lot. So, you still pay your Part B premium with Medicare Advantage or Medicare Part C. You pay your Part B premium and some plans do subsidize that premium a little bit. You also have limitations if you go on Medicare Part C. You have limitations on switching over to any type of other senior coverage.
So, this is an important decision to make really right on the very front end. Again, you always will be looking at signing up on Medicare for either A, B, and a supplement plan, or a C plan, which is all inclusive. A, B, and C. Think of those as together.
A brief mention on healthcare sharing ministries. Healthcare sharing ministries, or HCMs, these are membership groups whose members share religious or ethical beliefs, and they pay their monthly dues that are really used to pay the other members expenses. So, people think of those monthly dues as premiums. They're not technically premiums. They work the same way. They're actually monthly dues. So essentially members make monthly payments, similar to premiums. And those funds are used to pay medical expenses for others in the ministry.
Now, in addition to this, you have to make sure that you have a Part D coverage. Sometimes, D, (drug plan), is included in your Medicare Advantage, which is Part C. Not always. So you have to check with the plan to see what is covered and whether you will need a separate D plan. If you go with the original Medicare, which is A and B, and then add in a supplement plan, again, that's MedSup or Medigap, you will need to add in a Part D plan that will not necessarily be covered by your supplement plan.
The supplement plan company may offer a Part D coverage, but it is separate and you do sign up separately. So Medicare Part D, the drug plan, is a standalone prescription drug plan offered by private insurance companies. Once again, it helps cover the cost of prescription medication. And you can enroll in a Part D plan if you have Medicare A and B. Maybe if you have a Medicare Advantage plan.
So are you confused yet? Are the listeners confused? This is a terrible thing that they have put on seniors.
Jim Uren: Yeah, it gets very complicated very quickly.
John Bever: And so as a result, it's really important to carefully review and compare your available options. And you're going to consider a lot of factors such as premiums, your deductibles, your co-pays, your networks, your prescription drug coverage, and choose what's best for you.
We do really recommend working with a knowledgeable advisor. And I would stress knowledgeable advisors. While there are a lot of people that are familiar with this in our industry, not all are knowledgeable.
Jim Uren: That's true, that's true. So John, when can I sign up for Medicare?
John Bever: Well, there's our favorite phrase, it depends.
When it comes to things for seniors, oftentimes that's the answer. Happens with Social Security, also happens with Medicare.
So the first thing you want to look at is, are you covered at work? If you're covered at work, you can wait until you lose that coverage. Now check with HR and check with your benefits because some companies require you at age 65 to switch over to Medicare. Some will allow you to stay on the company policy. So we're thinking about age 65, but the first thing you really need to take a look at is what is available at work and can you continue past 65. Now this only covers companies that have 20 or more employees. So if you're with a very small employer, uh, you will be moving to Medicare at age 65.
So if you don't have group plan coverage, then your 65, regardless of when you collect Social Security. And you are eligible to sign up three months before to three months after turning age 65. So you have a six-month window there. Three months before your 65th birthday, three months after. And that would be to sign up for Part A and B.
However, there are different requirements for your additional senior coverage based on the type. So, if you are going with a Medicare Supplement Plan, you have to sign up for that within six months of obtaining your A and B coverage. And that is if you're going to be, uh, entering when you're turning age 65.
If you are signing up for a Medicare Part C plan, a Medicare Advantage plan, then you must sign up within two months after losing your group coverage. And D is also within two months after losing your group coverage. So I have some clients that kind of get caught in to that situation where they're signing up after losing their group coverage at age 65 and they do it within the three months after they just made that window. But they didn't get their D within the three months, they may have a penalty on the Part D.
Now you do have a, a special enrollment period that applies for various situations. And this is when you become eligible. So it doesn't matter when you turn 65, you have this special enrollment period where you can start. You don't have to wait till the annual enrollment, which is at the end of the year.
There are some other situations that would bring in a special enrollment period, and that would be when you lose your company coverage. So let's say your company will cover you past age 65, you stay on that coverage, and then you retire at age 67 and a half, and it's not the end of the year when there's open enrollment. You have a special enrollment period where you can get your coverage in place.
Another important thing, you must be a resident of the U.S. So if you're thinking about retiring outside the U.S., you're not going to be covered by Medicare. You will have to get other coverage for wherever you're going to be located.
And I had an interesting case many years ago, actually a Canadian citizen who came down here to the United States. And this client, a husband and wife, were thinking along the lines of the Canadian rules. And they didn't quite get the time frame right in their mind, and they signed up a little bit late, so they had a penalty. So it's really important to keep these dates straight in your mind.
Jim Uren: Absolutely, because as you said, John, there are penalties that can apply if you miss these deadlines, and you want to avoid those. And so what are the steps for actually signing up for Medicare when we're ready to do?
John Bever: Well, it depends on what type of coverage you're going to go for. So when it comes to signing up for Medicare and private health insurance, here are a couple of different things.
The first thing that you're all going to do, whether you're going for A and B and supplement, or whether you're going for Advantage C, everybody, you need to explore your options and you need to start no later than the year you retire. In fact, I recommend a couple of years before you retire to start to get your mind in gear with this, with your advisor. And get ready for robo calls and junk mail.
And uh, if you are going to be covered under group coverage, you need to compare the cost and the benefits of staying with the group versus going with senior coverage. So explore your options. That's the first thing that you have to do.
I've been working with a client in the last year and we know when he's going to retire. It is going to be at the end of the year, but we keep checking on things because he has a very fluid situation with a potential disability. So even though you explore your options, they actually may change throughout the year that you retire. So number one, explore your options.
Number two, decide your direction. What are you going to go with? Are you going to go with A and B with a supplement? Are you going to go with A and B and a healthcare sharing ministry? Or are you going to go with Medicare Advantage Part C?
Number three, then you actually sign up. So you're going to be signing up for Original Medicare on the Social Security website. Or you're going to be signing up for Medicare Advantage on the Medicare website.
You want to make sure that you start this process three months prior to turning 65, if you're going to be doing this in the year that you turn 65. And when you sign up again, it's important to know your deadlines. And then watch for your Medicare card in the mail.
So now that you're signed up for Medicare, let's assume you're doing Medicare Original A and B, and now you need a supplement plan or a healthcare sharing ministry. Well, now you need to sign up for that supplement plan. That is separate from signing up for Medicare A and B. Then you will sign up for Part D.
So if you're going to do C, those steps are all combined. Signing up for Medicare and signing up for what you might think of as the extra coverage, that's all done in one shot. And if it includes the Part D coverage, that's also included. And that is an advantage for some people to choose the Medicare Part C. But then you want to confirm your coverage.
So Medicare Part C is actually offered by private insurance companies. People think it's being offered by Medicare, but it isn't. It is through a private company. What happens is Medicare actually pays the company and the company manages your care within the premium structure that they receive.
So it's important to confirm that your coverage is in place and you want to confirm that with the insurance company. And then finally you can relax. So once you get through that, that process, then you are covered and it's usually pretty seamless thereafter.
So let's go through this again. So if you're going to go with original Medicare part A and B, and you sign up for original Medicare through the Social Security administration by going to ssa.gov or calling their toll free number, or even visiting a Social Security office. If you're going to be signing up for Medicare Advantage Part C, then you will enroll in that on medicare.gov. That's www.medicare.gov. And then if you are going to be bringing in private health insurance, then you would need to go with directly with that health insurance company signing up. Sometimes you can do that online. Sometimes you'll be working directly with an agent.
And with all of these, remember you may be staying with your employer sponsored health plan. Some companies offer supplement insurance with Medicare A and B. So this is again, where it's very important to explore your options and know what those are. You can get that information from your HR department at your company.
So there's a lot of twists and turns in this process. Do not hesitate to reach out and ask for help. You will actually find the people at Medicare are fairly helpful with this process. And the website, I can't stress this enough, it is actually a very helpful website.
It has improved dramatically over the years. They've made it easier to understand. There's a lot of links that you can click on that you can explore deeper. So it's a really good place to go to get additional information.
Jim Uren: Excellent. Yes, it is a great source. And, we utilize it a lot, too, to get the absolute latest. So, John, in signing up and doing this whole process, which, as you already alluded to, can get pretty complicated. What are some of the pitfalls and traps that people need to be watching out for?
John Bever: Yes, we've already referred to one of them and that is the penalties. So there are penalties if you are late and those penalties are permanent. You're not paying a one-time penalty, boom, I'm done with it. This penalty gets added to your monthly premium for the rest of your life. So on Part A, you will pay the premium twice the amount or twice the number of years that you didn't sign up. So whatever that Part A premium is that is covered, you don't have to pay it typically, it's paid for by the government. But if you do not sign up, you're going to pay that for twice the number of years that you did not sign up for Part A.
Part B, there is an extra 10% penalty on top of your existing premium for every year you miss. So if you miss three years, you're going to have a 30 percent additional premium on your Part B.
Part D, they do this monthly. It's an extra 1% for each month that you are not covered. Now, it's interesting because there is a 63-day grace period. Why 63? Don't know. Just making it more complicated, but there is that grace period if you are uncovered.
Second trap, HSAs. If you are funding an HSA, that's wonderful. You can use your HSA once you're on Medicare, but you cannot fund it. In fact, you are technically supposed to stop funding that HSA six months prior to signing up. for Medicare because Part A actually starts six months prior to the date you sign up.
Is that complicated enough? So that's why you need to actually stop your HSA six months prior to signing up for Medicare. And there is a tax penalty on that. If you, uh, end up funding the HSA beyond the deadline.
Number three, you can sign up with a Medicare supplement company up to one year prior to age 65 enrollment. But be careful, don't rush that decision. And there may be companies that really want you to get signed up. “Hey, get going right away.” If you know exactly what you're going to do, you've worked with an advisor, you know which direction you're going, that can be helpful. But there really is no rush because you have that six-month period, three months around your 65th birthday on each side, where you can go ahead and get signed up for both Medicare and your supplement policy.
There's a fourth and these are the robocalls. Believe me, your phone will ring off the hook with these robocalls. So first thing you want to make sure that you do, go on the do not call list if you haven't done that. Get your phone number on the do not call list in the year that you retire. But don't let the noise paralyze you. You get a lot of junk mail. You're going to get these calls. And some people it just paralyzes them and then they don't even know what to do. Watch out for that. Just be ready for it. It's not the end of the world. You can work through that and actually get yourself signed up, apart from all that noise that's going on around you.
Also, with Part D, it's not a one and done. Part D, which is your drug coverage, if you have that as a separate coverage, which means that you are on original Medicare A and B plus a supplement plan, you want to review that every year.
Even some Medicare Advantage C plans have a separate D coverage that you sign up for. You can actually change your coverage on Part D every year during open enrollment. Open enrollment occurs from the middle of October, October 15th, to December 7th every year. And you can actually go on the Medicare website, medicare.gov, and search D plans.
Now the way these D plans work is that each plan may have a preferred pharmacy where you're going to get a different drug cost based on the plan that you're on. And it's very specialized to the drugs that you're on. So, Medicare Part D, they actually have tiers of coverage based on where your drug falls in these tiers.
So, Tier 1 is typically very common drugs, very inexpensive. Tier 4, very expensive. So, you want to go on that site, plug in your preferred pharmacy, if you have one. Plug in the specific medications that you're on. And it will actually rank for you all the different plans that are specific to your area. Again, if you're a snowbird, or you travel a lot, you want to make sure you take that into consideration when you are searching Part D plans.
And then lastly, one other pitfall and trap. The Center for Medicare Services, which is CMS, it can actually be pretty slow in their processing of claims. So CMS is the one that actually handles all the claims. Everything gets put into the centralized bucket of CMS and sometimes they're on top of it and you'll get your notices on, uh, any amount that you may owe, you get those pretty quickly. Sometimes it will come quite late. And this particularly happened during the pandemic where they got behind on processing and people were starting to pay amounts that they really didn't owe, but they hadn't received the final notice from CMS.
Jim Uren: John, are there any other traps we need to be aware of?
John Bever: There is a lot of confusion around long term care costs. And again, long term care costs generally are not covered by Medicare. It's interesting. According to a June 2022 report by the Congressional Research Service, Medicare ends up paying for about 18 percent of nursing costs.
It's not a lot, but it certainly is more than nothing. And, that is an average though. So think about this, you've got some stays that are very, very short and some that are longer. So Medicare may be paying the first 20 days for a lot of people, and they might not last much longer than 20 days before they pass on. So, it may look like Medicare is covering 18%, but in reality for a specific situation where you are going to be in care for a while, you really don't have any coverage by Medicare.
As an example of this, my father suffered a massive heart attack in 2010 at age 87, and he was moved to a nursing home for rehabilitation. So, Medicare covers the first 20 days in skilled care, if you go in through the hospital. After 20 days, you must show improvement. And in those 100 days that they may potentially cover, you actually have a $200 a day copayment for days 21 through 100. So, Medicare will cover the first 20 days. After that, you have a copay.
Now, my father's situation, he declined rapidly with a congenital heart failure and was transitioned to hospice care. So really there was nothing to pay. First 20 days was covered by Medicare for the skilled nursing care and then he was under hospice care until the end.
So the bottom line on long term care is do not count on Medicare. For that, you need a separate long term care policy or at least a long term care plan. And this actually does take up quite a bit of retirement planning, figuring out how that cost will be covered.
So let me go back and cover this again on what you need to do for Medicare. Most people will sign up at age 65 unless they have group coverage.
If you have group coverage, then you need to check with your group plan to find out if that coverage extends past age 65. You will need to contact Medicare. If you're actually going to sign up for your Medicare Original A and B, you will actually do that through the Social Security website. And there are links back and forth between medicare.gov and ssa.gov that make this pretty easy to navigate.
If you choose Original Medicare A and B plus a supplemental coverage, MedSup or Medigap, you want to cover Uh, you want to make sure you look at the grid of all the different coverages that you can choose from. There is an alphabet soup of this, of the type of supplement plan that you can choose. We're not going to cover that in this podcast because it is a fairly detailed and complicated. It is better for you to go on the Medicare website and find that information on the Medicare website because it actually does change every year in terms of co pays and deductibles.
If you choose you want more of an HMO approach, you want managed care, and you're choosing Medicare Advantage and Medicare Part C, then you're going to be jumping to finding out the networks that are in your area. And you'll look at those networks. Once you make your decision, think of it as irrevocable. It's not entirely irrevocable, but think of it that way as you approach this. With Medicare Part C, when you sign up for that, in the first year, you can switch over to Medicare Supplement. But after that, you're really stuck on Medicare Advantage Part C, so consider that.
If you sign up for Original Medicare A and B, plus a supplemental plan on top of that, you can switch to C later on down the road. So, there you have it. Everything you may wanted or didn't want to know about signing up for Medicare, but it's a very important process for you to go through and to make sure you have your ducks in a row before that day comes.
Jim Uren: Yes, and as we've outlined, getting coverage post-65 through Medicare is certainly far more complicated than what we're used to pre-65, right?
John Bever: Yes, it is.
Jim Uren: So it is important that you get your ducks in a row, and again, we urge you to work with a knowledgeable advisor. Uh, not even all licensed agents or CERTIFIED FINANCIAL PLANNER™ professionals or advisors in general necessarily have the expertise to guide you.
So make sure you work with someone who does. And again, we strongly recommend you visit medicare.gov. It is a well done site and provides lots of information. Uh, that's wrapping up the episode.
We'd appreciate if you would like and subscribe to the podcast so you don't miss any future episodes. You can see our show notes for this episode at phase3advisory.com/podcast. There we'll also make available to you a number of flowcharts that we have related to Medicare, such as how avoiding the IRMAA surcharges and avoiding Medicare enrollment penalties, et cetera. Lots of valuable resources that we'll make available again at phase3advisory.com/podcast.
And again, you're always welcome to contact us with questions and we'd be happy to help whenever we can.
John Bever: All right. So. We always like to finish these podcasts with something that we are thankful for. So Jim, today, what are you thankful for?
Jim Uren: You know, I'm thankful for my parents. They're going to be coming and visiting us soon. And, though they don't live close by, it's fun to have them and, it's great for them to visit us and the grandkids. And let's face it, the grandkids are certainly the bigger draw than we are. But it's fun to have them and looking forward to spending some time with them in a couple weeks here.
How about you, John?
John Bever: I am thankful for medicare.gov, believe it or not. So they've just done a really good job at improving this over the last decade. And I can't stress that enough. You know, usually I say something a little bit more personal, but it just seems really appropriate for this particular podcast to say, I'm really thankful for it. It's a very, very well done.
My wife and I are getting close to that age. And so I've been checking it out, not that I didn't check it out before for the industry, but looking at it personally is a little bit different experience. And I have to say, it's very understandable. My wife has been able to look through that and actually follow it quite well. So I do highly recommend it. And, uh, I'm very thankful for it because they actually have done a good job with it.
Jim Uren: They have. Well, thank you all for joining us. And you can find out more about us at phase3advisory.com. Thanks for listening.
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