Medicare Can Be Confusing: 6 of Your Top Questions, Answered

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Julia Yellow

Most people on Medicare report that they are very satisfied with their health care coverage — but the program is complicated. Medicare features an alphabet soup of plans, coverage choices, premium levels and enrollment rules.

The New York Times recently invited readers to submit their questions about Medicare. Today, we’re responding to some of the most frequent ones.

What kind of monthly premiums for either original Medicare or Advantage can I realistically plan on budgeting, especially considering inflation?

Health care inflation has been running about double the rate of general inflation. HealthView Services, a research and consulting firm, expects annual health care inflation to run an average of 5 percent to 5.5 percent through most of the coming decade.

The standard monthly premium for Part B (outpatient services) this year is $135.50; Medicare’s trustees forecast annual increases averaging 5.9 percent through 2028. Enrollees in traditional Medicare can expect inflation of 6 percent if inflation for Medigap premiums is included.

Among Medicare Advantage plans (Part C), 49 percent of plans that include drug coverage will charge no additional premium beyond Part B next year, according to the Kaiser Family Foundation. Plans that do have additional premiums for drugs will charge an average of $36 next year, Kaiser says.

According to HealthView, a 65-year-old couple using original Medicare this year will spend around $10,300 on premiums for prescription drugs and Medigap, and various out-of-pocket costs. In 20 years, their costs are projected to be around $33,000 annually (future dollars).

“The compounding effect of inflation is significant,” said Ron Mastrogiovanni, HealthView’s chief executive.

How can I get insurance for dental care? I am 78 years old and this is my largest uncovered medical expense.

Dental care is a critical component of preventive health care; research has shown clear links between poor oral health and chronic diseases like diabetes, as well as pain, chronic infection and reduced quality of life. Yet over all, nearly two-thirds of Medicare enrollees have no dental insurance, according to the Kaiser Family Foundation. That means a majority pay for their care out of pocket or go without.

Original fee-for-service Medicare does not cover most dental care, and it also does not cover hearing or vision care. Dental care is covered only in very limited circumstances, for example, if it is necessary as part of a covered procedure.

Many Medicare Advantage plans — the managed-care private alternative to the original program — include some level of dental coverage. Next year, 90 percent of Advantage enrollees will have access to some level of dental benefits, according to Avalere Health, a research and consulting firm. Sixty percent will have access to a plan covering restorative services; 78 percent will be able to get coverage for X-rays and cleanings.

Like other dental insurance, Advantage plan coverage levels have caps. “‘Limited’ would be a good word to describe it,” says Sean Creighton, a managing director in the policy practice at Avalere.

The percentage of Medicare Advantage plans covering hearing and vision care is rising by similar percentages, he adds.

In most cases, these services are being offered without an additional premium. Plans are paid based on a benchmark per-capita rate Medicare uses to pay for original Medicare enrollees; when Advantage plans bid below that rate for matching original Medicare benefits, they are permitted to use the difference to offer extra benefits.

“Advantage plans are growing as a share of total enrollment, and they are trying to attract members from original Medicare and in competition with each other,” he added. “Dental, vision and hearing benefits are very popular.”

Original Medicare enrollees have the option of adding a commercial stand-alone dental policy. For example, a Delta Dental P.P.O. plan offered in New York City carries a monthly premium of $48, with an annual deductible of $50 and an annual per-person payment limit of $1,500.

Many of the current Medicare for All proposals would add coverage of dental, vision and hearing care.

Someone called me claiming to be from Medicare and I gave out my Medicare number. Should I be concerned?

Medicare generally does not initiate calls to enrollees — with a couple of exceptions. Medicare health or drug plans can call current members. And customer service representatives from Medicare (1-800-MEDICARE) may call if you have left a message, or if a representative indicated that you would receive a return call.

Never give out your Medicare — or Social Security — number to anyone who calls you on the phone, sends email or makes a personal contact. Your personal information, including your Medicare number, should be shared only with health care providers, your insurers or trusted counseling services, such as the State Health Insurance Assistance Program.

“Any unexpected call from someone claiming to be from Medicare is a huge red flag, especially if you didn’t call first,” says Amy Nofziger, director of fraud victim support at AARP.

AARP’s fraud help line (877-908-3360) has noted a recent increase in phone schemes, usually aimed at persuading people to order equipment or services that are then billed to Medicare. “A big one lately has been DNA genetic testing kits,” Ms. Nofziger said. The Medicare program isn’t the only victim of the phony bills, she said. “Sometimes, Medicare will deny the claim and then the perpetrator mails a bill to the enrollee. You might get a bill for up to $10,000, which is pretty scary for people.”

If you suspect you’ve been victimized by fraud, alert Medicare that a scammer may have your identifying number so that your account can be flagged and monitored. And, keep a careful eye on the monthly explanation of benefits that Medicare sends, looking out for any suspicious charges.

“If Medicare feels the problem rises to the level of needing to provide you a new Medicare number, they can do that,” Ms. Nofziger added.

Issuing new numbers became easier recently after the government revamped its system. The old Medicare cards used Social Security numbers, but those were phased out as part of a federal anti-fraud initiative. New cards that were mailed to all enrollees during 2018 and 2019 use a unique, randomly assigned number.

Why does Medicare set my 2019 premium cost using my 2017 income? I am newly retired as of August 2019 and my Part B premium is $433 a month. I’m also paying more for my prescription drug plan. My income in 2019 is much lower than it was in 2017.

High-income Medicare enrollees have been paying surcharges on Part B and Part D premiums since 2007. These so-called Income-Related Monthly Adjustment Amounts (IRMAA) affect a relatively small share of the Medicare population — about 7 percent this year, according to federal data — but they are steep.

The standard Part B premium requires enrollees to pay 25 percent of the government’s total per-capita program costs; the surcharges require high-income enrollees to pay anywhere from 35 to 85 percent more, depending on their income. The Part D income-related surcharge is calculated as a percentage of the national average cost of the standard drug benefit, using the same percentages and income thresholds used for Part B IRMAA.

IRMAA is determined by your modified adjusted gross income, which includes the adjusted gross income reported on your tax return, plus tax-exempt income.

For many retirees, the big surprise is the look-back that determines whether IRMAA is owed — income often declines in retirement, but your initial premium could be set using pre-retirement income levels. The Social Security Administration determines whether surcharges are owed from data in the most recently available tax return it obtains from the I.R.S.; for 2020 premiums, the agency will use income tax data provided this year from 2018 tax filings.

“The sticker shock comes in the form of the Social Security benefit,” Mr. Mastrogiovanni adds. “Not only is the Part B premium deducted, but also the surcharges. So people go through their planning to see what Social Security will generate, but people in these high-income brackets could lose up to half of their gross Social Security benefit.”

In your recent discussion of limitations of Medicare Advantage plans, you did not include information about improper claims denials and the difficulty people have pursuing appeals. That certainly should be part of your coverage.

A report last year by federal investigators did find that Advantage plans have a pattern of inappropriately denying patient claims. The Office of Inspector General at the Department of Health and Human Services found “widespread and persistent problems related to denials of care and payment in Medicare Advantage” plans. The report examined appeals filed by patients and health care providers from 2014 through 2016, and found that Advantage plans themselves overturned the denials in 75 percent of cases.

However, very few claim denials are appealed — just 1 percent during the three-year period reviewed in the inspector general’s report.

The Advantage payment model reimburses plans a preset amount per patient; that may be incentivizing plans “to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits,” the report concluded.

“We see plenty of denials by Advantage plans that shouldn’t be denied, and wouldn’t be if the patient had been enrolled in original Medicare,” says David Lipschutz, associate director and senior policy attorney at the Center for Medicare Advocacy.

Among the most common problems, he says, are early hospital discharges, denial of care in a skilled nursing facility or home health care.

I had an accident this year that has required bilateral knee surgery — I was in the hospital for a week and a residential rehab facility for physical therapy and treatment of related problems for one month. Now I am home with a home health nurse weekly, and visits from a physical therapist five days a week. I also have adaptive equipment. My recovery process will be at least five more months, carrying over into 2020. Can my Plan G Medigap supplemental insurance provider cancel me for 2020?

Original Medicare enrollees often add a Medigap supplemental plan to cap out-of-pocket expenses — and that comes in especially handy when a major medical problem arises. You can choose among a dizzying array of standardized plan options with varying degrees of coverage; Plan G is one of the most comprehensive, covering hospital and doctor co-insurance costs, hospice care, coinsurance for skilled nursing facilities and hospital deductibles.

Fortunately, Medigap coverage does not disappear when you need it.

“No Medigap plan can cancel you for spending too much,” says Chris Hakim, senior vice president of Medicare at eHealth, an insurance exchange. “The only way you can lose coverage is if you don’t pay your premiums.”