The Florida Bar

A Non-Medicare Lawyer’s Journey into Medicare

March 26, 2020

[Disclaimer: This is not a legal analysis of Medicare. In addition, it represents the author’s opinion and is a tongue in cheek analysis of Medicare. Some knowledge of Medicare is necessary in reading this.]

I have always been a prepared person and so when it came to Medicare I started researching and analyzing Medicare at least a year in advance. I thought that I would be eligible upon turning 65 and that the options would be:

(1) staying with an employer group health plan,

(2) original Medicare Part A and Part B [1] while taking the financial risk associated with co-pays, deductibles and co-insurance not covered by Medicare,

(3) original Medicare (Part A and Part B), with a Medicare supplement insurance policy and a Medicare Part D prescription plan [2], or

(4) A MedicareAdvantage plan with prescription drug coverage [3]. I “thought” that Medicare Part A and Part B did not cover prescription drugs. I knew that if a person did not sign up for Medicare during his/her initial enrollment period that he/she might have to pay a penalty unless the reason for not signing up for Part B was due to coverage under a group health insurance plan and the person might potentially have underwriting issues with Medicare supplemental insurance or a Medicare Advantage plan at a later It seemed all simple enough. I just needed to fill in the details, but I was wrong about a number of things.

Through my research, I discovered the following:

  1. One is eligible for Medicare, if (s)he, otherwise qualifies for Medicare, the first of the month in which (s)he turns age 65, so coverage can begin before age 65. [4]
  2. Medicare Part B, covers, but not, necessarily, in full, certain prescription drugs under limited conditions, such as certain drugs infused through durable medical devices, some antigens, certain injectable osteoporosis drugs, blood clotting factors if you have hemophilia, Erythropoiesis-stimulating agents, certain transplant/immunosuppressive drugs, among others. [5]
  3. If you do not buy Medicare Part A when you are first eligible for it, your monthly premium may go up 10% for each 12-month period you could have had Part A but for not signing up for Part A, for a period of time twice the number of years you did not sign So if you delayed Part A for 2 years, you will have to pay the higher premium for 4 years. If you qualify for premium free Part A Medicare, there is really no reason not to sign up when you are eligible. If you do not sign up for Part B when eligible for it or, if applicable, during your initial enrollment period, then you may have to pay a late enrollment penalty. [6]
  4. Federal law only permits changes from one Medicare supplemental policy to another if certain special circumstances exist, you have guaranteed issue rights, or you are within 6- months of the initial open enrollment period for a Medicare supplemental. [7]

 

As I continued to wade further into Medicare supplemental insurance available in Florida, by county, Medicare Part “D” standalone prescription coverage available in Florida, by county, Medicare providers, and the various, by Florida county, MedicareAdvantage plans and their net- work providers in Florida, I discovered a more complicated world — a world of multiple Medicare supplement plans (all pre-determined by governmental requirements), [8] Florida Medicare Part D prescription plans, and Florida Medicare Advantage plans. I later had the shocking discovery that (1) Part B premium is income-based, [9]( (2) the difference between participating and non-participating Medicare providers can create havoc with your healthcare costs if you do to pick the right Medicare Supplement plan, [10] (3) “limiting charges” and “excess charges” [11] need to be considered and (4) beware of the “private contract” trap. [12] Being a lawyer, I, of course, later could not stop myself from engaging in “what if ” scenarios.

WHAT IF my current physician or any of my medical facilities are not participating or non-participating providers under Medicare Part A or Part B or not a provider under the Medicare Advantage plan? Answer: Too bad or go under an employer group health insurance plan that includes current physicians and medical facilities.

WHAT IF my medical provider currently takes Medicare assignment as a Medicare Part A and Part B participating provider but stops taking assignment? Answer: If I have a Medicare supplement policy that covers excess charges and my medical provider switched to a non- participating provider, then I would not have any additional out of pocket costs, but I might have to pay costs upfront and be reimbursed by Medicare supplement insurer.

WHAT IF my medical provider is in net-work under a Medicare Advantage plan but later leaves the network? Answer: Too bad, but later try to change to a Medicare Advantage plan where (s)he is a provider or to Medicare Part A and Part B with a Medicare Supplement policy, IF I am, then, eligible to do so.

WHAT IF my medical provider leaves the Medicare Advantage network and it was a closed network plan, stopped being a participating or non-participating provider in Medicare by opting out of Medicare completely, and I am not eligible to change plans or insurers, while I was under treatment for some horrifi c disease? Answer: change physicians midstream, negotiate the cost with self-pay, max out my credit cards, sell assets….

As I thought I was getting the hang of Medicare, then along came the international scare associated with 2019-nCOV. I, then, asked myself the question, “Depending upon my Medicare coverage, who would pick up the cost if I had been an unlucky tourist in Wuhan who, upon returning to the United States, tested positive, ended up being treated with anti-virals and experimental drugs in a hospital not selected by me?” What would happen if I had to be treated while abroad? Answer: If it happened on or after February 4, 2020 , and I was tested in the United States, original Medicare/a Medicare Advantage plan would pick up the cost of the test, but the provider cannot get paid until April 1, 2020. Original Medicare Part A and Part B and Medicare Advantage plans will cover clinical laboratory diagnostic tests and, once discovered and approved, a vaccine. If I had been enrolled in a qualified research study, certain costs would also be covered. [13] Whether there would be any payment under a Medicare supplement policy that covered foreign travel while on vacation, if testing and treatment occurred in a foreign country, the answer is unknown, particularly if the test was prior to February 4, 2020, not a test similar to that developed in the United States and the treatment is not of the type that would have been given in the United States. Given such uncertainty, a travel medical policy would still appear to be necessary.

All humor aside, one’s determination of the best Medicare medical coverage requires very careful consideration, on an individual basis, of taxable and future taxable income, current and potential future medical providers, current health, one’s own and family health history, and financial assets, as well as luck. To start your own personal journey into Medicare, go to medicare.gov.

Andromeda Monroe is an insurance regulatory attorney/consultant, who has been practicing law for almost 40 years, primarily representing insurers on corporate and regulatory matters. She is  licensed to practice law in Ohio and Florida. She is looking forward to semi-retiring in June.


[1] Medicare Part A coverage is hospital coverage; Medicare Part B coverage is medical coverage. Medicare does not cover all medical or hospital services or the cost of all covered services. Among other services, it does not cover dental services, optometrist visits, long-term care, dentures, experimental treatments but it may cover certain costs in qualifying clinical research studies. Part A and Part B do not cover most prescription drugs. Medicare Part D is necessary for prescription drugs, but some Medicare Advantage plans under Part C include prescription drugs as part of the plan. See https://www.medicare.gov/your-medicare-costs/part-a-costs, https://www.medicare.gov/your-medicare-costs/part-b-costs, https://www.medicare.gov/what-medicare-covers/whats-not-covered-by-part-a-part-b and https://www.medicare.gov/coverage/clinical-research-studies for details.

[2] Medicare supplement insurance pays the deductibles, co-insurance, and copays that original Medicare does not pay, subject to certain limitations. Medicare Part D is a stand-alone prescription insurance coverage. See https://www.medicare.gov/drug-coverage-part-d, https://www.medicare.gov/Pubs/pdf/11579-medicare-costs.pdf, https://www.medicare.gov/supplements-other-insurance/whats-medicare-supplement-insurance-medigap for details.

[3] Medicare Advantage plans are insurance plans where the federal government contracts with private insurers to provide Medicare Part A and Part B coverages. Medicare Advantage plans can include prescription drug coverage. Medicare Advantage plans include the benefits of some Medicare supplement plans and can also provide some additional benefits. See https://www.medicare.gov/sign-up-change-plans/types-of-medicare-health-plans/medicare-advantage-plans for details. Most Medicare Advantage plans in Broward County are HMO’s, have closed networks if a PPO or require referrals to specialists and none include the Mayo Clinic, based upon this author’s research of Medicare Advantage plans and conversations with certain insurers.

[4] See https://www.hhs.gov/answers/medicare-and-medicaid/who-is-elibible-for-medicare/index.html for Medicare eligibility criteria.

[5] See https://www.medicare.gov/coverage/prescription-drugs-outpatient.

[6] See https://www.medicare.gov/your-medicare-costs/part-a-costs/part-a-late-enrollment-penalty, https://www.medicare.gov/your-medicare-costs/part-b-costs/part-b-late-enrollment-penalty, and https://www.medicare.gov/sign-up-change-plans/how-do-i-get-parts-a-b/should-i-get-parts-a-b for details.

[7] See https://www.medicare.gov/supplements-other-insurance/when-can-i-buy-medigap/switching-medigap-policies.

[8] Medicare supplement plans are standardized and classed as Plans A – N. Plan F is no longer available for new Medicare enrollees in 2020. Plans in Massachusetts, Minnesota and Wisconsin are standardized differently. See https://www.medicare.gov/supplements-other-insurance/how-to-compare-medigap-policies.

[9] For 2020, because it can change each year, premium is as follows : $144.60 for a single individual with federal tax  return modified adjusted gross income (“MAGI”) equal or less than $87,000 or a married individual with a federal joint tax return MAGI equal to or less than $174,000; 202.40 if a single individual with  federal tax  return  MAGI greater than $87,000 but less than or equal to $109,000 or a married individual with a federal joint tax return MAGI greater than $174,000, but less than or equal to $218,000; $289.20 for a single individual with  a federal tax  return MAGI  greater than $109,000 but less than or equal to   $136,000 or a married individual with a federal joint tax      return MAGI greater than $218,000 but less than  or  equal  to  $272,000  ;$376.00  if  a  single  individual  with  a federal tax return MAGI  greater than $136,000   but less than or equal to $163,000 or married individual with a     federal joint tax return MAGI  greater than $272,000 but equal to or less than $326,000;   $464.70 for a single   individual with a federal tax return  MAGI  greater than  $163,000  but less  than  $500,000  or  a married  individual with a joint tax return MAGI  greater than $326,000 but less than $750,000. $491.60 for a single individual with a  federal tax return MAGI  greater than or equal to $500,000 or a married individual with a joint tax return MAGI    greater than or equal to $750,000. See https://www.cms.gov/newsroom/fact-sheets/2020-medicare-parts-b-premiums-and-deductibles for additional premium amounts based upon income.

[10] Participating Medicare providers: have an agreement with Medicare, take assignment of benefits; must submit their claim directly to Medicare;; takes full payment for all fully covered Medicare charges and can bill you only for the Medicare permitted amount. Non-participating Medicare providers: can charge you more than the Medicare- approved amount for certain services, up to 15% over the amount that non-participating providers are paid; receive 95% of the Medicare fee schedule amount; may want all costs not paid by Medicare upfront and for you to seek reimbursement from your Medicare supplement insurer for costs outside of Medicare limits. See https://www.medicare.gov/your-medicare-costs/part-a-costs/lower-costs-with-assignment.

[11] A “limiting charge” is what a non-participating Medicare provider can charge you, up to 15% over the amount that non-participating providers are paid by Medicare. This is the equivalent of the excess charge that you can arrange to be covered under certain Medicare supplemental plan, the best being in 2020 for newly eligible Medicare recipient, Plan G. See https://www.medicare.gov/your-medicare-costs/part-a-costs/lower-costs-with-assignment.

[12] Medical providers can opt-out of Medicare and can enter into a private contract with you. They are neither participating or non-participating providers under Part A and Part B. If this occurs, Medicare will not pay for any service from this provider, even if it is a service covered by Medicare and your Medicare supplement policy will not pay as well. You, of course, can get non-covered Medicare services from such a provider, as well as from your Medicare provider. See https://www.medicare.gov/your-medicare-costs/part-a-costs/lower-costs-with-assignment.

[13] See https://www.medicare.gov/blog/medicare-now-covers-coronavirus-testing and https://www.medicare.gov/coverage/clinical-research-studies.