The John C. Bogle Center for Financial Literacy is pleased to sponsor the 38th Bogleheads Live with Ellen Glasworth and Lauren Rabe.
Diane Gaswirth and Lauren Rabe answer your questions about Medicare.Diane Gaswirth has over twenty years of experience specific to the Medicare insurance field. She gained her first exposure to the Medicare arena during an internship while earning her Masters of Science degree in Health Services Administration. Diane traveled throughout California, conducting a speaker’s series educating beneficiaries on Medicare and long-term care. She joined PacifiCare Health System in 1990 to promote their Secure Horizons Medicare plans and today oversees Medicare product sales at United Healthcare. As a sales director, Diane has developed key relationships with medical providers, agents and agencies. She is similarly focused on developing strategic alliances with financial professionals who assist Medicare consumers in their retirement planning, focusing on the health and wealth connection.Diane lives in Poway, California, with her husband and two sons. In her down time, she enjoys cooking, staying active and spending time with her family and friends. Lauren Rabe is an Agent Manager for the San Diego market, in UnitedHealthcare’s Medicare & Retirement division. She works remotely from the UHC headquarter office in MN supporting our agent distribution channels. Lauren has been with the company for almost five years, with a background in Direct to consumer sales and product.
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Thank you for joining us for the 38th Bogleheads® Live, where the do-it-yourself investor community asks questions to financial experts live. My name is Jon Luskin, and I’m your host. Our guests for today are Diane Gaswirth and Lauren Rabe. They’re going to be answering your questions about Medicare.
Let’s start by talking about the Bogleheads®, a community of investors who believe in keeping it simple, following a small number of tried-and-true investing principles.
This episode of Bogleheads® Live, as with all episodes, is brought to you by the John C. Bogle Center for Financial Literacy, a 501(c)(3) nonprofit organization dedicated to helping people make better financial decisions. Visit boglecenter.net to find valuable information and to make a tax-deductible donation.
Before we get started on today’s show, some announcements. For the next Bogleheads® Live, we’ll be discussing the boring but important topic of long-term disability insurance. If you’ve got a long time until you retire, you want to check that episode out.
That’ll be Thursday, February 16th at 12:00 PM Pacific, 3:00 PM Eastern. You can see the full list of future guests at bogleheads.org/blog/bogleheads-live.
Also, if you haven’t checked them out, videos from the 2022 Bogleheads® Conference are now available online. If you weren’t able to attend our annual event, check out boglecenter.net/2022conference to see what you missed.
Before we get started on today’s show, a disclaimer. This is for informational and entertainment purposes only and should not be relied upon as a basis for investment, tax or other financial planning decisions. Thank you to everyone who submitted questions ahead of time. We got a lot of questions about Medicare. We might not have time to answer all of them.
Let’s get started on today’s show with Diane Gaswirth and Lauren Rabe. Diane Gaswirth has over 20 years of experience specific to the Medicare insurance field. Lauren Rabe is an agent manager for the San Diego market in United Healthcare’s Medicare and retirement division.
Diane and Lauren, thank you for joining us for Bogleheads® Live. Let’s start with a little bit of Medicare 101. For folks that don’t know the basics of Medicare, what is Medicare? And give us a little bit of a rundown of how it works.
Lauren Rabe: I think it might also be helpful just to add, “Who is Medicare for?” Those individuals who are 65 and older or who have been on Social Security Disability for more than two years would be also eligible.
Diane Gaswirth: There are four parts to Medicare. There are Medicare Parts A, B, C, and D. Medicare Part A, just in general terms, is coverage for inpatient hospitalization or skilled nursing care. It also covers some healthcare services as well.
Part B of Medicare covers medical services and outpatient care, such as doctor visits, specialist visits, and outpatient surgery. And it also includes other things like ambulance, physical therapy, and those types of services among others.
Lauren Rabe: Now, in general, Original Medicare does not cover everything. You might be stuck paying 20% of an expensive inpatient hospital bill, and there’s no out-of-pocket maximum on that amount. Original Medicare does not cover prescriptions. They don’t cover annual physicals. There’s no benefits for vision, dental. So, you don’t want to depend just on what A and B covers. You want to have something to go along with that.
Diane Gaswirth: Medicare Part C is an alternative way to get your Medicare benefits, also known as Medicare Advantage. So, “Medicare Advantage” and “Part C” are terms that are used interchangeably. It is offered through private insurance companies and it basically combines your Medicare Part A and B benefits, includes prescription drug benefits, which is also known as Part D of Medicare, packages them all together in a convenient plan that covers additional services that Original Medicare doesn’t cover.
So again, Part D stands for prescription drugs and an individual can get Part D coverage either through a Medicare Advantage plan or through a standalone prescription drug plan.
So, your options are Medicare Advantage, which cover your hospital, medical, drugs, and other services not covered by Medicare or a Medicare supplement plan, which covers what Medicare covers and then you would add on that separate Part D or prescription drug plan.
If anybody decides to join a Medicare supplement plan, it’s very important that they know that they will also need to join a standalone Part D or prescription drug plan. That’s because Medicare supplement plans don’t cover prescription drugs.
Two premiums in that instance. One for your Medicare supplement plan, one for your Part D plan. One premium, if any, under your Medicare Advantage or Part C plan.
So in summary, those are the four parts of Medicare.
Jon Luskin: To say what our guests said a little bit differently, when you first reach age 65, signing up for Medicare, you’re going to have two options. Option #1: You’re going to opt for a bit of a comprehensive plan called Medicare Advantage, also known as Part C. You’re going to pay one additional premium for a bundle of benefits. Or, instead of getting Medicare Advantage, you could get two additional coverage options to accompany the Original Medicare. That’s going to be a Medicare supplement, AKA a Medigap Plan, and Part D, that prescription drug coverage.
This one is from Thomas, who writes, “I’ll be turning 65 soon. How do I estimate the cost of Medicare?”
Lauren Rabe: It’s going to be a little bit different for everyone, dependent on income, for a couple of reasons. One, I’ll say that Part A of Original Medicare is no-cost as long as you have enough work credits. Part B as in boy, is again for hospital, and that’s what does have a monthly premium of $164.90 for 2023. That is the first thing someone is going to want to consider – that Part B cost each month.
Second, depends on income bracket. So, if you have an income more than $97,000, you may incur a penalty called IRMAA – Income Related Monthly Adjustment Amount.
Jon Luskin: That is $97,000 for an individual or twice that ($194,000) for married filing jointly.
Lauren Rabe: And that starts at $65.90 in addition to that Part B premium each month. So that’s one consideration, again, that someone will want to consider when budgeting for their Medicare expenses.
And then of course, also, would be what plan they choose. A Medicare Advantage plan, the all-in-one plan as Diane described, is oftentimes $0 in addition to that Part B premium. There can be cost to Medicare Advantage plans.
The other route would be a Medicare supplement. Those can cost as much as $100 or $200 or $300. And so again, it kind of depends on the plan that they choose. But I would automatically consider the Part B cost each month, then any Income Related Monthly Adjustment Amount each month, and then again what plan they decide to choose. And if they choose a plan with copays, they’d want to consider how often are they going to the doctor, and then they can do the math that way as well.
Jon Luskin: Looks like Tecmo is back. He can ask his question.
Tecmo: I’m someone who’s looking to retire early, so I assume I’ll need to get my own insurance up until it sounds like 65. And then at that point, can you just rely on Medicare?
Lauren Rabe: Up until you turn 65, most likely you’ll have your coverage through an employer. You may also have it through an individual exchange. When you turn 65, assuming again you have enough work credits, which most people do if you’ve worked in this country most of your life, you’ll receive Parts A and B through Social Security. And Part B, again, has that $164.90.
Diane Gaswirth: Prior to turning 65, if you do retire then, you’ll want to get some other type of coverage in place until such time that you would be eligible for Medicare. And turning 65 makes you eligible to enroll in Medicare Parts A and B.
And as Lauren said earlier, Part A is an entitlement. So, you really have to enroll in Part B and you can do that up to 90 days prior to your 65th birthday. You do that through the Social Security Administration or through an agent, then you’ll receive your Medicare card in the mail with your Medicare Parts A and B effective dates. And that’s what would enable you to join either a Medicare Advantage plan or a Medicare supplement plan, depending on your preference.
Tecmo: Say if I retire at 50 to 65, I get my own insurance that costs a bajillion dollars, then I go to 65 and then I drop that and get advantage?
Diane Gaswirth: You would no longer need your under-65 plan. You would simply exchange that for a Medicare plan of your choosing, either Medicare Advantage or Medicare supplement.
Jon Luskin: Let’s jump to a question I got beforehand from the Bogleheads® Forums. This question is from username “mhalley” who asks:
“Should you go with a cheaper plan, i.e., Medigap Plan G each year if you have been satisfied with your current plan? If so, what yearly or monthly discount makes it worth the hassle of switching? Assuming that you can pass underwriting.”
Jon Luskin: For those who aren’t insurance nerds, know that underwriting is a process by which the insurance company decides if you’re someone that they want to insure or not. Passing underwriting means that the insurance company has decided that taking you on as a risk is something they want to do, making you eligible to purchase insurance coverage through them.
Not passing underwriting means that you can’t buy insurance coverage because the insurance company has decided that you’re too risky to insure.
Lauren Rabe: A couple of things here. So, Part B again is a part of Original Medicare for hospital. When they ask the follow up question example of Medigap Plan G for a cheaper Plan G, that’s actually considered a supplement. I want to assume they’re talking about supplements in this case because we don’t determine the rate of Part B that’s delegated by Social Security.
So again, should you be shopping around for a new Medicare supplement each year? Every carrier most likely will see some adjustment in premium every year. Most people will choose to stay unless there’s something really major that would make them want to change. Medicare Advantage plans, on the other hand, I’d say people do tend to do a little bit more shopping around. But again, remember that with a Medicare supplement, too, there is underwriting. And so, with underwriting it’s not always guaranteed you’re able to be accepted into another plan.
So again, with Medigap Plan G, most people would probably stay, but again, it doesn’t hurt to browse your options.
Diane Gaswirth: The only thing I would add to that is Medicare supplement plans have a provision in place where you can change your plan every year in the state of California under what we call the birthday rule.
So every year on your birthday, you can switch to an equal or lesser rich plan. So, you do have the option of doing that. You just want to do your homework and make sure you know what those other plans cover because you could stay with the same company and opt for a different plan within the Medicare supplement options. And you can do that without underwriting. That’s the really nice piece of it. Don’t have to worry about whether you might be accepted in that plan or not.
So the answer is yes, you can switch Medicare supplement plans once you elect a plan, and you can do it every year. I would just look at, what the benefits are, what the cost is, and if it provides any additional benefits like discounts on specific services that Medicare doesn’t cover.
Jon Luskin: This one is from username “buffinita” from Bogleheads® Reddit, who asks:
“Can a strategic divorce be financially beneficial when looking at Medicare and possibly other social services? In this scenario, one person has an incurable genetic disorder, which will qualify as medically disabled.”
Diane Gaswirth: There are certain health conditions that would qualify someone to join Medicare at an earlier age. For example, end stage renal disease or Lou Gehrig’s disease. So, if someone has a specific type of illness, that would make it an option for them to join and enroll in Medicare prior to turning age 65. That could certainly help financially.
With respect to Medicare eligibility, the genetic disorder or example that was given would not qualify, but perhaps if that individual needed certain prescription drugs that fall under Part B of Medicare instead of Part D, there could be some financial help. There is also financial help for people who qualify based on limited income and resources.
Jon Luskin: Looks like I’ve got a speaker request from Rick Ferri, host of the Bogleheads® on Investing podcast.
Rick: I have a question about SSA-44 and what to do if you’ve been working at 63 and you have a high income, but now you’re 65 and you’re no longer working and your income drops way down because you’re retired and yet you get a bill for a very high Part B cost. What does Form SSA-44 do and how quickly does it get enacted? Can you go over this please?
Diane Gaswirth: So, for many people, when they’re working, they are drawing a salary that’s higher than when they retire. The way this works with Medicare Part B and calculation of the Part B premium that Lauren addressed earlier is Social Security will take a look at the amount that you file – your gross adjusted income – that you file on your tax return, and they will actually base it on your tax return from two years prior.
So for 2023, for example, they’ll base your Part B premium amount on your 2021 tax return. So, the Part B premium will be calculated based on the amount you made two years ago. Every year that will adjust. In other words, it will catch up to you each year as your income normalizes in retirement and goes down.
Having said that, there is an appeal process that you could go through and then see if they’ll make an adjustment. But typically, it is based on your tax return from two years prior.
Rick: There’s a form SSA-44 called a Medicare Income Related Monthly Adjustment Amount that you could fill out and send in almost immediately to adjust the amount. On the form it says if you don’t want to fill the form out, you can call the Social Security office and they will do it for you. But again, it’s for people who were working when they were 63, so they have high income, so their IRMAA amount would be quite high.
But now that they’re 65, they’re no longer working, but they don’t want to pay that high IRMAA amount based on their 2021 or 2020 taxes. So, they fill out this form and they call the Social Security office and they will adjust it based on what you believe your Modified Adjusted Gross Income is going to be. And so, you don’t have to pay it in and then eventually get it credited back.
Jon Luskin: SSA-44 Medicare Income Related Monthly
“If you had a major life-changing event and your income has gone down, you may use this form to request a reduction in your Income Related Monthly Adjustment Amount.” Which is just a geeky way of saying how much you’re paying for Medicare.
Jon Luskin: This one is from username “buckeye7983” from the Bogleheads® Forums who writes:
“Under what conditions might one expect better medical care, broader provider access, or quicker access to specialists with Medicare Advantage as compared to Original Medicare?”
Lauren Rabe: This individual is comparing Medicare Advantage with Original Medicare. Again, keeping in mind that Original Medicare covers some things but not others. So just to reiterate, we are proponents of individuals having something in addition to Original Medicare.
What I really want to compare is Medicare Advantage and Medicare supplement, because I think that’s what the user might mean is oftentimes you pair the supplement with Original Medicare.
So in comparing these two, all of those factors are important, right? Medical care, provider access, access to specialists, et cetera. And all of these things are obtainable through both a Medicare Advantage and a Medicare supplement plan option. Again, both will supplement your Original Medicare. Both will help with those things.
But the choice depends on personal preference and really budget takes a big play. So, in comparing the two, a Medicare supplement works to supplement your Original Medicare. These plans do not have a provider network, so that’s one of the greatest things about a Medicare supplement. There is no network.
You can go anywhere in the US, as long as they’re willing to accept Medicare, and they’ll bill you. So, what that means is that you also don’t need a referral. So again, these plans, Medicare supplements are great for people who travel. They don’t want to have to worry about the referral.
They’re often more expensive. So that’s the drawback is they will have a higher monthly premium. Like I said, it could start at $100 up to $300 or more a month in addition to your Part B premium, where a Medicare Advantage plan typically has a very low premium in addition to your Part B.
So, what I like to say is, really considering budget and health status when you’re turning 65. If you know that you’ve got some kind of a health issue, and you don’t want to have to worry about paying a copay or a co-insurance every time you go to the doctor and you know ahead of time that you’re probably going to have a lot of hospital or doctor visits, Medicare supplement plans are a great option. You’ll never have to worry about network or referrals. And if you go with say, a Plan G, which is the most popular, you won’t be paying any copays or co-insurance. Again, you pay that flat monthly premium. You don’t have to worry about anything else.
Where if somebody is maybe healthier or they can’t afford the premium of a Medicare supplement, Medicare Advantage options are really great as they’re considered an all-in-one plan. So, these plans do include prescription coverage where Medicare supplement, you’d have to buy that separate. And Medicare Advantage plans have additional benefits such as ancillary like vision, dental, hearing. Gym memberships even. So again, they’re more of an all-in-one plan with a lower monthly premium, more of a pay-as-you-go style plan as there may be more copays and co-insurances.
And keep in mind, with Medicare Advantage, there is a network. So, if someone’s aligned with one medical group, they’ve got their primary doctor, they like the managed care system, then it’s really a great plan for them. So again, when it comes to budget, some people will lean towards Medicare supplement if they can afford that monthly premium, others will go the Medicare Advantage route. If, again, they want that lower premium, they don’t mind the network, and they’ll pay the copay every time they go to the doctor.
And again, I wouldn’t usually be a proponent for just Original Medicare. You’ll want something to go along with that.
Jon Luskin: This one is from username “nahtonoj” from the Bogleheads® Forums who writes:
“According to the Medicare website, if I have coverage after 65 through my job or my spouse’s job, I can sign up for a Medicare Part B and D when my employer provided coverage ends, and I will not have to pay a penalty for Part B so long as I enroll within the eight months after the employer provided coverage ends.
To avoid the late enrollment penalty in Part B, do I need to show any kind of documentation to prove I had the employer-provided coverage? What document will I need to provide if I had credible coverage in this situation for Part D?”
Diane Gaswirth: If an individual is over age 65 and is still working and receiving health benefits through their employer, they can safely delay enrolling in Part B until such time when their employer coverage ends or they retire – whichever comes first. And that individual will not have to pay a late enrollment penalty as long as the employer provides them with what we call “proof of creditable coverage.” What that means simply is just that the employer’s Part D coverage or prescription drug coverage is as good or better than what Medicare provides.
And the form that the individual would get from their employer is called the CMS L564 form. The best approach to this is to work with your human resources department to receive that form, complete it, and then submit it to Social Security. They will know not to charge you the late enrollment penalty for Part B if you have had creditable employer coverage in place.
The same thing applies for Part D. This will cover that individual. And it’s just important to know that it is absolutely okay to delay enrolling in Part B when you are still employed and have creditable coverage provided by your employer. So, you won’t be penalized when you eventually leave your employer’s coverage.
Jon Luskin: This one is from username “DetroitRick” from the Bogleheads® Forums who writes:
“For those buying a Medigap policy in states where future changes require medical underwriting, one of the more difficult things to evaluate is future policy premiums. Today’s cheapest provider can become relatively expensive almost overnight. Do you have any recommendations for things to look at, to assess an insurer’s relative premium stability over time?”
Diane Gaswirth: Couple things to consider here. So, if the question is about switching plans, one Medicare supplement plan to another Medicare supplement plan, there is no underwriting required if an individual uses the birthday rule that I had described before.
Now, I think in terms of trying to figure out how to assess an insurer’s relative premium stability over time, there are a few things they can look at. They actually can contact the company or the Department of Insurance to get information on the rate history. So, that’s an important thing to look at. What is the rate history over time?
I think another thing to consider is the size of that block of business. So, membership, because in theory, Medicare supplement plans are insurance products. So, it’s the law of averages, and it’s risk. So, the law of larger numbers factors into this.
And then I would also look at the financial strength of the company as well as their commitment to the particular product line. There are a few companies that just focus on Medicare products. So, that would be another thing that I would consider in doing your research as far as which Medicare supplement plan you might want to join when you are Medicare eligible.
The whole underwriting process is established to make sure that insurance companies set the right premium for their products to help keep overall rates in line for as long as possible.
Jon Luskin: This one is from username “AlwaysLearningMore” from the Bogleheads® Forums who writes:
Any general thoughts on skipping Medicare Part B to supplement FEHB – Federal Blue Cross PPO – for a high net worth couple married filing jointly, with retirement income that will place them in the highest one or two IRMAA brackets?”
Diane Gaswirth: Clearly, again, the IRMAA or the Medicare Part B premium for higher wage earners is a consideration because it can cost those individuals up to $560 more for their Part B premium in 2023 than for someone who would pay the baseline Medicare Part B premium of $164.90.
I think what they’re asking is, gosh, is it okay for me not to enroll in Part B to save myself that additional $300 to $400 on my Part B premium if I have coverage through my employer, which is the Federal Employee Health Benefits Program?
And so the answer is yes. If an individual is working past 65 and has employer health coverage through the Federal Employee Health Benefits Program, it’s not necessary for them to enroll in Medicare Part B. Enrolling in Part B is what qualifies them to join a Medicare Advantage plan or a Medicare supplement plan, but they already have that coverage.
So, it won’t supplement the coverage they have now. It is just simply not necessary to purchase it until their coverage through the Federal Employee Health Benefits Program ends. In other words, their PPO plan through Blue Cross is perfectly sufficient for what they need now. They would only need to enroll in Part B when their employer coverage is no longer available either through their choice or their employer’s.
Jon Luskin: This one is for username “Duzz78” from the Bogleheads® Forums who writes:
Could your two guests explain what the term “medically necessary” means related to land ambulances?”
Diane Gaswirth: How is “medically necessary services” defined in relation to ambulance services? I guess the easiest way to speak to that would be from how we know that service is covered.
If an individual requires ambulance transportation to the nearest emergency room, they would call 911 and then the paramedics would be dispatched and then the ambulance would take them to the nearest hospital.
From a Medicare definition, anytime an individual calls 911 and is transported by an ambulance, that would be considered medically necessary care.
If an individual has Original Medicare only – not any other coverage option – Medicare would pay and approve 80% of the cost of that ambulance ride and the Medicare beneficiary would be responsible for the other 20% of that cost.
f, however, that individual had a Medicare supplement plan in place that provided coverage for ambulance services, they would pay whatever the cost sharing is on the Medicare supplement plan.
Let’s take Medicare supplement Plan G, which is the most comprehensive plan. It’s the most expensive, but it’s the most comprehensive. On that plan the Medicare beneficiary would pay a $0 cost. It would be covered in full.
Now, let’s say the Medicare consumer has a Medicare Advantage plan. The individual on a Medicare Advantage plan would pay whatever co-payment is associated with their plan. And just to give you an idea, that one-time co-payment could be anywhere from $100 to $300. A one-time payment of that amount.
Number one, ambulance services are considered medically necessary when somebody calls 911 and needs to get to the nearest hospital. What the Medicare beneficiary would pay depends on what type of coverage they have.
Jon Luskin: This one is from username “celia” from the Bogleheads® Forums who writes:
When should we know the hundred drugs for which Medicare will be negotiating a lower price and the timetable when the lower price will take effect for each drug?”
Diane Gaswirth: I think what this Boglehead® is asking is about the Inflation Reduction Act. You all might be aware that the Inflation Reduction Act was put into law, and it takes effect this year for certain provisions of it, particularly the ones that relate to prescription drug costs.
What the plan or what this act intends to do is lower prescription drug prices in Medicare through price negotiations with drug manufacturers. It also serves to lower the cost of insulin drugs for Medicare beneficiaries to no more than $35 for a one-month supply. And it also looks to cap out annual out-of-pocket prescription drug costs for Medicare to a maximum of $2,000. And that won’t take effect until 2025.
So, the question about the specific drugs in 2023. So, sometime this year, Medicare will select and announce the first 10 drugs that are going to be negotiated. The law requires that those 10 drugs are chosen from the list of the highest spending brand name Medicare Part D drugs that don’t have any competition.
The negotiated Medicare drug prices for those first 10 drugs will be available, but not until 2026. And then it goes from there. So, Medicare will choose and negotiate 15 more Part B drugs for 2027, 15 more for 2028, and then 20 or more in the years after that. So, it’s a graduated program.
But I think the most important thing right now is the provisions that take effect for 2023 include the cost for insulin, which will not exceed $35 for cost-sharing for a 30-day supply. And the other component of that, too, is that vaccines are covered by this program, which include all Part B and Part D covered vaccines administered to adults age 19 or older. This also includes the shingles vaccine, and all of these vaccines will be covered at a $0 cost share. Those are the highlights of the Inflation Reduction Act in terms of how it impacts prescription drug costs and considerations moving forward.
Jon Luskin: Diane and Lauren, any final thoughts before I let you go?
Diane Gaswirth: Well, Jon, we just appreciate you having us. We just thank you for allowing us to provide this education for everyone.
Lauren Rabe: Absolutely. As Diane said, thank you so much for having us on. It’s fun to get on here and share a little bit more. Thanks, Jon.
Jon Luskin: That’s all the time we have for today. Thank you to Diane and Lauren for joining us today. And thank you for everyone who joined us for today’s Bogleheads® Live.
For the next Bogleheads® Live, we’ll be discussing the boring but important topic of long-term disability insurance. If you’ve got a long time until you retire, you want to check that out. That’ll be Thursday, February 16th, at 12:00 PM Pacific, 3:00 PM Eastern.
Until then, access a wealth of information for do-it-yourself investors at the John C. Bogle Center for Financial Literacy at boglecenter.net and bogleheads.org, the Bogleheads® Wiki, Bogleheads® Twitter, the Bogleheads® YouTube channel, the Bogleheads® on Investing podcast with host Rick Ferri, Bogleheads® Facebook, Bogleheads® Reddit, and local and virtual chapters.
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