Hidden Legal Pitfalls in Medicare 2020

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Parents Are Hard To Raise® S03 Episode 137 Transcript

Announcer 0:00

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Diane Berardi 1:13

Welcome to Parents Are Hard To Raise, helping families grow older together without losing their minds. I’m elder care expert Diane Berardi.

Diane Berardi 1:23

Longtime listeners will recognize my next guest as our go to expert on all matters elder law. If I were to list all of his credentials there’d be no time left in the show. So let me just say he’s a certified elder law attorney practicing in center County, Pennsylvania with the firm Steinbacher, Goodall and Yurchak. Philadelphia magazine named him a Super lawyer in elder law as they have every year since the category was created. He’s a fellow of the National Academy of elder law attorneys and currently serves as president of the National Elder Law foundation. Attorney Amos Goodall, Welcome to Parents Are Hard To Raise.

Amos Goodall, Esq. 1:59

Thanks Diane.

Announcer 2:01

So you’re going to talk to us about Medicare. Could you kind of refresh our audience about what is Medicare and how it works?

Amos Goodall, Esq. 2:12

I will be happy to Diane. And I’d like to start with a quote that I think really summarizes it. It’s a court case. And it really summarizes this area of the law. This was a quote by Judge Friendly who was a circuit court judge in New York in 1976. He says, there has been developed a degree of complexity in the Social Security Act, and particularly the regulations, which makes them almost unintelligible to the uninitiated. Such on intelligibility is definitely unfortunate in the case of a statute, dealing or the rights of poor people, and I would add your old people. And that’s, that’s really what we’re talking about today is is a law that is as complex as any law that I know of. In fact, when I turned 65 I write a book on, I’m the author of a chapter of a book on elder law. And one of my chapter one of my chapters is Medicare. And I still had trouble determining what to do for myself.

Diane Berardi 3:15

Oh my gosh.

Amos Goodall, Esq. 3:17

So it is a, an area that is complicated and it is. We need to, we need to understand as much as we can going into it because we’re going to make decisions that are going to be with us for a while.

Diane Berardi 3:33


Amos Goodall, Esq. 3:34

So, Medicare is basically health insurance, health insurance program for folks who are age 65 and older, as well as some younger people who have disabilities. And it’s like any other insurance, you’ve got to pay the premium to acquire it and it has various components. There are four main components of Medicare as it stands today.

Amos Goodall, Esq. 3:59

There’s something called it Part A, something called Part B, something called Part C, which is a hybrid of a and b and possibly Medicare Part D, which is private health insurance for prescriptive drugs. So those are the components of Medicare. And I’d like to give you a little bit more detail.

Amos Goodall, Esq. 4:19

Part A deals with inpatient health services, I’m sorry, inpatient hospital services, some hospital extended care services, and some home health services and hospice services. So if you go into the hospital, the hospital bill goes to Medicare Part A.

Amos Goodall, Esq. 4:37

The doctor who treats you is going to be covered by Part B, and I’ll talk about Part V in just a second. But what you what you need to do to get Part A is you need to be either over 65 and be fully insured under the retirement program. In other words, have a sufficient number of quarters of work, that you’re entitled to Social Security retirement. Typically when you reach full retirement age… Here it starts to get complicated. But yeah, for me for retirement age of 66. For other people, it might be 67. For our parents, it probably was 65. And whatever our full retirement age is, Medicare kicks in at the age of 65. So if you are 65 years of age, you are entitled to Medicare part and fully insured, you’re entitled to Medicare Part A. You are if you’re under 65, and you’ve been receiving Social Security disability benefits for 24 months, you’re entitled to Medicare Part A. And if you are over 65, and you’re not fully insured, then you have you can buy in but apart from that people who are qualified for Medicare do not have to pay for Medicare Part A.

Diane Berardi 5:48


Amos Goodall, Esq. 5:49

Now I’m going to go to part B. Part Part A is the hospital Part B is the doctor. Medically necessary services, preventive services like physician services, supplies, diagnostic tests, etc. Those are all part B. And what do you have to do to get Part B will you have to be entitled A Medicare Part A, You have to be a citizen and resident the United States are and certain non residents who have been lawfully admitted for permanent residents and whoever retired here, whoever resided here for at least five years. And there is a premium for Part B, there’s a base rate premium, and then there is a an additional charge based upon your income two years ago.

Diane Berardi 6:35

Really, okay.

Unknown Speaker 6:36

The premium varies year by year. In 1976, for example, the premium was $121. Now it’s somewhat higher. The additions to the premium cost based upon income raised the cost several up to several hundred dollars a month. So you’re admitted to the hospital where the hospital bill goes to part And the doctors bill goes to part B. Medicare Part B has a number of deductibles and co insurance and it has a number of things that it does not cover. For example, that there’s a part of the deductible that is so much a year, there’s a part of the Co-insurance that is 20% of whatever the amount Medicare approves for the bill. And then there are some coverage limits on things like psychological and occupational therapy and things like that. So people, if they are planning ahead, will purchase at the same time they qualify for Medicare Part B, they will purchase something called Medicare Supplement Insurance or Medigap.

Diane Berardi 7:42


Amos Goodall, Esq. 7:43

Those are policies that pay for things that Medicare Part B doesn’t cover. There actually are basically nine plans and there are 10 features that different plans cover and you may choose the plan that best meets your needs and best meets your wallet, frankly, when you are purchasing that insurance.

Amos Goodall, Esq. 8:08

Social Security administration maintains a website where you can compare Medigap plans and to prepare for this conference today I went on the site and looked and there are 40 plans in center County.

Diane Berardi 8:20

Oh my gosh.

Amos Goodall, Esq. 8:21

Are that one can choose from. And you look at the plans that they’re all required to have the same coverage in the same area. So if a plan is going to offer Part B coverage for part B, coinsurance, or co payment, all the plans in that category will offer that coverage and you have to decide well, which of the coverages of the extra coverages do I want to pay for? So for example, if I don’t ever plan to travel abroad, I probably won’t buy a plan that includes coverage or if I’m outside the country,

Diane Berardi 8:52

Right. Okay, makes sense.

Unknown Speaker 8:54

If I’m deciding on things I may or may not choose a coverage that pays for the cost of blood transfer. So you look at the Medigap insurance policies you purchase the policy that you best think fits your needs. Now, that’s part in Part B.

Amos Goodall, Esq. 9:10

Part C or Medicare Advantage is a private insurance program that’s been around now for about I’m going to say the last 15 years that basically covers your medical expenses, same things that traditional Medicare Part A and Part B cover, okay, and it must cover one more thing, at least one more thing that’s not covered. For example, it may have dental coverage, it may have vision coverage. Around here in Center County, many of the Medicare Advantage programs include gym memberships, because they want people to work out and of course, stay healthy longer. So it’s more of a managed care plan. It’s the government pays the company that administers the plan certain amount of money per person, and then they administer The insurance program. There are some advantages to Medicare Advantage. There are some disadvantages. One of them is you’re dealing with a private insurance company. And so your ability to challenge things. It’s not based upon federal law, but it’s based upon the insurance contract.

Diane Berardi 10:16

Hmm. Okay.

Unknown Speaker 10:18

So you have, you have Part A and B or you have Part C. And the cost for Part C is sometimes is as little as nothing more than the part cost of Parts A and B because they’re relying on on the, what they’re getting from the federal government. Clearly, if you have a more expensive plan, you’re going to get more coverage. And the CMS has a website Social Security Administration has a website that will allow you to compare the coverages of various plans.

Amos Goodall, Esq. 10:50

By the way, my website is Goodall.org and after we finished this conversation, I’m going to post on the website, a couple of PowerPoint presentations that discuss this, as well as the links to the comparison tools that I’m talking about.

Diane Berardi 11:09

Perfect. That’s wonderful.

Unknown Speaker 11:11

So you look at what insurance you want to buy you, you decide on do I want Medicare Part A and be traditional or do I want Medicare Advantage? And then you have to think about drugs. And, you know, might you might say this kind of drives you to drugs, but I’m not talking recreational drugs, I’m talking about prescription drugs. [laughing]

Diane Berardi 11:31

Oh, my God. [laughing]

Unknown Speaker 11:32

So, the Part D program, the Medicare prescription drug program is incredibly complicated and I hope I can do justice and explaining it. Each provider each insurance company has made a list of the drugs that it covers. So if you take a particular drug, you can look to see whether that that drug is covered the particular plan that you are considering buying, and again, there’s a website that will let you compare these things. So is your drug on that list that’s called a formulary. And it’s the list of drugs that the company will provide coverage for. And then you haven’t finished because the next thing you have to do is figure out where in their tier of drugs does the drug you need fit. And you may need a drug that is called a tier one drug or which is basically generic drugs. They pay more of the cost of that than if you had a tier five drug which is the highest tier drug which is perhaps an experimental drug, in which case they made it they may or may not pay. I analyze it will a Senate Committee on Homeland Security and Governmental Affairs listed the 20 most prescribed brand name drugs for seniors, and I analyzed for center County, the 31 prescription drug plans That covered those 20 items. And the cost of the plans ranged from $13 a month to $168 a month. And although probably no one takes all 20 of those brand name drugs, the annual costs with additional out of pocket expense is roughly $15,000 a year.

Announcer 13:22

And we’re going to continue talking with Amos Goodall. But first, if you are a woman or there’s a woman in your life, there’s something you absolutely need to know.

Diane Berardi 13:32

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It’s not like it was in our grandmother’s day. Today just going to and from work or to the mall can have tragic consequences. The FBI says a violent crime is committed every 15 seconds in the United States. And a forcible rape happens every five minutes. And chances are when something happens, no one will be around to help.

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Announcer 15:35

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Diane Berardi 16:10

You’re right Dolly. There’s so many really cool new ways to listen to our show. It’s hard to keep track. You can join the 180 million listeners on Spotify. You can listen in your car at the gym, or pretty much anywhere on your smartphone with Apple podcasts and Google podcasts. You can get us on Apple TV, direct tv, Roku. And like Dolly said, you can even ask Alexa to play the show for you. It’s great because you don’t have to be tied to a radio anymore. You can listen when you want where you want for as long as you want. And if you’re listening to the show one of these new ways, please do me a big favor, share this new technology and help someone else learn about the show and show them a new way to listen.

Diane Berardi 16:55

So Amos, we were talking about the Medicare drug coverage. region the tears.

Unknown Speaker 17:01

Yes. And I apologize to your listeners. That was a very dry presentation. But I think I needed to present that information in order to set the stage for what I really wanted to talk to you about today and that’s that we are presently in what is called an open enrollment period. It’s a time when people can change their coverages. So, let me give you one more piece of dry information and then we’ll get going on the open enrollment.

Diane Berardi 17:30

good. The juice, right? The juicy stuff. Okay, go ahead.

Amos Goodall, Esq. 17:34

Okay, so when you turn 65, you’re supposed to enroll in Medicare. That’s called the initial enrollment period it begins. It’s a seven month period beginning three months before you turn 65 and ending four months afterwards.

Amos Goodall, Esq. 17:50

Now, you should enroll at the beginning of the period. Because if you wait until you’re 65, or you wait until you’re a few days after 65 There will be a gap in your coverage, your old coverage will not cover you. And the new Medicare coverage won’t kick in. So if you but if you enrolled at the very beginning of the open enrollment period, or the initial enrollment period, you can make sure you don’t have any lapse in coverage.

Amos Goodall, Esq. 18:16

If you have not done that, if you fail to enroll when you’re supposed to enroll, you can still enroll later, you can enroll in something called a general enrollment period, but that’s only between January 1 and March 31 of each year. And the sanction is, first of all, that you have to enroll during that period. Secondly, that you don’t get coverage until July. And third of all, you’re going to have to pay a penalty.

Amos Goodall, Esq. 18:41

Oh my gosh.

Amos Goodall, Esq. 18:42

And the penalty for part B, Part A if you’re not going to have to pay for part A there’s no penalty for that. But Part B is 10% for each full year of delay for lifetime. So if you’re five years late, that means you’re going to be 50% more For the rest of your life.

Diane Berardi 19:01


Amos Goodall, Esq. 19:02

It’s it’s important that folks enroll in Medicare whenever they first can. Now some folks have something called comparable coverage or and that’s coverage, for example through an employer. And if they have that coverage, they can delay enrolling in Medicare as long as that coverages and force when that coverage ends, then their initial enrollment period would begin, or else they would have something called a special enrollment period, which is effectively the same thing.

Amos Goodall, Esq. 19:31

Now I want to caution your listeners that Cobra, many folks have heard of Cobra when I lose your job, you can keep your health insurance for several years after that if you pay privately, that is not comparable coverage. And if you have that, you turn 65 and you’re relying on Cobra, you’re going to suffer a penalty later.

Amos Goodall, Esq. 19:52

So if you’re enrolled in Medicare when you’re supposed to enroll it during your initial enrollment period or whatever.

Amos Goodall, Esq. 19:59

But what’s going on now? What’s going on now is that you’re in the open enrollment period when you’re allowed to change, you can change without penalty. So if you’re in traditional Medicare and you think, well, maybe I want to change my coverage and enroll in Medicare Advantage, and maybe not have to pay for my Medigap insurance anymore. This is the time to do it. This is the time to go on the website and compare the various plans and determine whether a plan that is Medicare Advantage would meet your needs at a better cost or whether you should you feel better staying with a traditional plan. And you can make your decision at that time. In a sense, Medicare Advantage is often like a sometimes like an HMO or sometimes like a preferred provider plan that if you go outside the network, you’re going to have penalties or you’re going to have to pay more. Whereas if you’re in traditional Medicare, you go to any doctor who’s enrolled in the Medicare program and you’re going to have the same benefits as you would anywhere else. So this is the time that you have that you can check to determine whether Should I stay with Medicare? Should I go to Medicare Advantage? Do I want to stay with the Medigap company I have one and maybe consider another Medicare.

Amos Goodall, Esq. 21:19

The open enrollment period is now through December the seventh and it’s for coverage which begins January the first so it’s there’s some time constraints.

Amos Goodall, Esq. 21:32

The other thing you need to consider is whether you want to change your prescription drug program. You’re going to have to go through that same horrible comparison analysis that I described a few minutes ago to determine whether some other drug program might better suit your needs. After all, your drug program if you have a particular drug that you’re taking. This is the time often that companies prescription companies change their formulary and they may say, Well, we’re not going to offer that drug anymore, or we’re going to move it into a higher tier so that it’s going to be more expensive. And you may, this would be the time when you can change companies without any penalty.

Amos Goodall, Esq. 22:14

I’m saying that there is no penalty there is unfortunately one penalty and that’s this. If you go from traditional Medicare the part A and B where you your program is through the government to Medicare Advantage. That’s smooth and seamless.

Amos Goodall, Esq. 22:29

If you go the other way, however, that’s also smooth and seamless as far as the medical insurance coverage is concerned, however, for the Medigap for the program that pays for the deductibles and the other things that you want to have some relief from having to pay. They in most that’s regulated by the states and in most states, there are four exceptions, but in most states, there’s a waiting period for the new coverage. If you are, you’re in the hospital and you thought your patient paid portion of the hospital bill was going to be covered by your Medicare Supplement Insurance Company. And it’s within that waiting period, it’s not going to be covered. So there is some disadvantage to transferring between Medicare between Medicare Advantage and going back to traditional Medicare. So I guess the rule would be if you know, you’re going to be sick. I not want to change plans. [laughing]

Amos Goodall, Esq. 23:31

Oh my gosh. So, are there a lot of changes coming, you know, down the pike for next year?

Unknown Speaker 23:39

Well, there are not a lot of changes for Medicare, the traditional Medicare and traditional Medicare Part A and B, those programs are going to be the same. The only thing that might change is that the cost if you’re being hit with a premium, because you have a summit high income, okay? That cost is going to be going up That seems to be always going up. And they, changed the brackets a little bit. But for most people that cost is at least going to be the same and maybe go up just a little bit.

Unknown Speaker 24:12

There are some special help that’s available to folks who are have limited income to pay some of those deductibles. That’s really not what we were going to be talking about today. But in the PowerPoints that I’m going to post on my website, it discusses programs like specified low income beneficiaries, and qualified beneficiaries and some other ones. And those are all some help that people have been paying some of those deductibles.

Unknown Speaker 24:39

But as far as Medicare Advantage goes, I’m not aware of any systemic, substantial systemic changes to Medicare Advantage at this time, although companies, their private insurances, right companies have the right to change anything about their plans that they can get past the state insurance commissioners. I believe that there’s a push now to allow the government to negotiate for the cost of prescription drugs. And I’m understanding that that cost savings may be used to provide additional coverage, possibly vision possibly dental under traditional Medicare plans, but I will believe that frankly, when I see it.

Diane Berardi 25:24

[laughing] yeah, okay, sure. So this is really overwhelming, right? How does someone know what to do?

Unknown Speaker 25:34

Well, there are there are, of course, insurance agents can help with the products that they sell you if you’re when you’re turning 65, your mailbox is going to be filled with advertisements from people wanting you to buy their Medicare Advantage plan. But most the but most states have a statewide office which will help you evaluate those people. plans in Pennsylvania it’s called Aprize. And I’ve I know some of the folks who man the telephones in that office. And they, they are very knowledgeable about the various programs available in Pennsylvania and while they won’t play favorites, that can help you analyze what your needs are, and point you to some of the some of the programs which seem at first blush to fill those needs. I believe that CMS also contains information rating the various companies as far as surveys as to satisfaction so you can take a look at if you’re going to buy from Company A, is it are people happy with it? Or is it is it better? Might you better go to Company B. So there is help available. Of course, I plug for my profession, certified elder lawyers, people who have the CELA credential have been trained and are experienced in advising seniors who were in entering this phase in their lives, and would certainly be a great resource.

Diane Berardi 27:05

Definitely, because this is tough. You know, this seems very tough to do on your own knowing what to do.

Amos Goodall, Esq. 27:11

It is. I mean, it’s the you have to answer basic questions. Do I want to go with a government program? Do I want to go with a private insurance? Yeah. Once you’ve done that, then which are the private insurance programs and if I’m going to use the government program, which are the Medigap policies, do I want to buy. Getting old is not for people who are faint of heart. That’s for darn sure.

Diane Berardi 27:31

Yeah, you’re not kidding. Oh, my gosh. And Amos, if you give us your website again, please.

Unknown Speaker 27:38

My website is goodall.org, and there’s a one line in it there are a thing at the top called resources in that in that if you if your readers or listeners will click on that, that button, it will take them to a list of a number of items that I have list have put up there, one of which will be the PowerPoints discussing this Medicare program. I know there will be a discussion of the open enrollment period. And finally, I will have the links that I’ve talked about that allow you to compare plans and determine exactly what’s available in your area. Enter your zip code and there you are.

Diane Berardi 28:21

Thank you so much], Amos, for all this information. Oh my gosh.

Diane Berardi 28:27

And Parents Are Hard To Raise family. I love getting your emails and questions so please keep sending them You can reach me at Diana Parents Are Hard To Raise.org or just click the green button on our homepage. Parents Are Hard To Raise as a counter sync media production. The music used in this broadcast was managed by Cosmo music, New York, New York. Our New York producer is Joshua Green, our broadcast engineer is Well Gambino, and from our London studios, the melodic voice of our announcer, Miss Dolly D.

Till next time, May you forget everything you don’t want to remember and remember everything you don’t want to forget. Thank you so much for listening and Happy Thanksgiving!

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