The Top 5 Most DENIED Services By Medicare Advantage Plans

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If you are on a Medicare Advantage plan, you need to know this.
Advantage plans deny claims more often than most people realize — and the services being denied are not obscure. They are everyday healthcare needs that real beneficiaries are regularly being told no to.

What most people do not know is that about 75% of appealed denials get overturned. That means a lot of people are paying out of pocket or going without care they were actually entitled to, simply because they did not know they could fight it.

Today, we are breaking down the top five most commonly denied services on Advantage plans and what you can do if it happens to you.

Bring your questions and call in live.

Transcript

SPEAKER_02 0:03

When you start Medicare, there's gonna be one of two types of plans that you are probably going to end up with. One of those types of plans, the insurance company gets to decide whether or not you get the healthcare service that your doctor recommends. And the other type, the insurance company has no say-so in. We're gonna be talking all about that, and you're going to learn everything you need to know so you can protect yourself and make the choice that is right for you. My name is Joshua Music. Welcome to Medicare School Daily. This is my dad, Marvin Music. And if you are confused about Medicare or you're confused about Social Security, and it's time for you to start taking your benefits, welcome, you're in the right place. We're so happy to be here with you today talking about all things Medicare. In just a moment, you're going to learn everything you need to know about prior authorizations so that you can make the choice that is right for you. If you have a question along the way or maybe a shit a story that you would like to share with us, maybe you have an experience with yourself or with a friend or a spouse that had a prior authorization nightmare. We would love to hear about that and talk to you about that. The phone number to call in is 800, pardon me, is 833-824-2004. 833-824-2004. Call in, ask your question, share your story, help all of us get a little bit smarter. You can have your questions answered from 11 a.m. to noon Central Time Monday to Thursday. 11 a.m. to noon uh Central Time Monday to Thursday 833-824-2004. So don't let that Medicare question go at go unanswered. Don't make a Medicare or a Social Security mistake. Get your questions answered from literally the nation's leading expert on Medicare. So, Dad, let's talk about uh these prior authorizations that happen on Medicare, the types of plans, what services are most commonly getting denied, and then how many is this affecting a lot of people or just a few people? Let's go through everything.

SPEAKER_00 2:02

Sure. So uh prioritizations are certainly not a new concept. They've been around for a long time. It's the way that insurance companies are able to control some of their cost. Uh one of the issues that you'll face, though, with the Medicare Advantage Plans is a tremendous amount of them. In fact, we know that uh uh 99 percent of all people that are on advantage plans are going to encounter uh pre-authorizations. Now, that doesn't mean that on every service, certainly if someone goes sees their primary care physician or get some basic lab work, things like that, that's not gonna have to be pre-authorized. But uh, the majority of services that we're gonna need are gonna have to be pre-authorized, especially anything that's going to be expensive. All right, so uh everyone will encounter these. And so let's talk about some of those issues that uh uh you know people are gonna have to face. The first one uh would be uh if you are going to get uh an MRI or a CAT scan or a PET scan. PET scans are a little bit more expensive than the other, but they're all expensive. And so your doctor says we need to check that out, or you're having some abdominal pain and we want to do a scan or an MRI. Well, the doctor has to recommend that service. Uh the insurance company has the final approval. They have to agree with what the doctors say. Now the truth is they may uh the the insurance company may say yes, but I have seen many times uh where they say no. Uh they actually uh deny the service, they don't think it's justifiable, they're not gonna spend the money, or they may make a person go through additional hoops, uh. Some things that uh they're gonna add to uh what the doctor uh is recommending. I've had plenty of people that um uh needed a hip replacement, full hip replacement. That certainly is a preauthorized service. Any kind of surgery that you're gonna have, whether it's inpatient or outpatient, uh, that is gonna have to be pre-approved. And so I've had uh clients that uh needed a full hip replacement, went through the pre-authorization process, and then uh the the decision was no, we're not gonna pay for a full hip. We will pay for you to have a rod inserted. Or uh doc is saying you need a knee replacement, and the plan says, no, uh, we want you to go to therapy for nine months first, and then we'll reevaluate that. And so if you never have to have a preauthorization, uh you're not gonna be troubled by this. But but rest assured if if you're going to need something that's expensive, uh uh uh any kind of inpatient-outpatient surgery, then you are gonna have to go through this process. Uh and they uh have up to 72 hours to make a decision. So not only uh may you not get it, but it could be delayed and sometimes even longer than that. All right? Okay.

SPEAKER_02 4:31

So uh So what types of plans generally once someone's on Medicare are there pre-authorizations? Okay. Because there's a lot of different plan options people are gonna have. So let's simplify that and help people understand. Trevor Burrus, Jr.

SPEAKER_00 4:42

You're talking about just general advantage plans?

SPEAKER_02 4:45

Or well I so I I guess you know the when somebody goes on Medicare, they're gonna probably go one of two ways, right? So there's a Medicare supplement plan, these are Plan G, plan N, those sorts of things, and there's Medicare Advantage plans. So we're talking about pre-authorizations that happen where?

SPEAKER_00 5:00

In with with Medicare Advantage plans.

SPEAKER_02 5:02

Okay. So on the supplement plan, that's the insurance company doesn't have any say-so.

SPEAKER_00 5:06

Never. Yeah, because supplemental plans, if you're on one, they follow Medicare. So if Medicare says we'll cover that knee replacement, that MRI, that CAT scan, you can have that, then the submental uh plan has no say-so whatsoever. They follow Medicare. They make no uh uh you know uh determinations whatsoever. In fact, what you'll see on the majority of carriers today, insurance companies, they will actually put on the front of their card no pre-authorization required. They have no right to delay, to deny whatsoever they're going to pay, whatever Medicare is going to pay.

SPEAKER_02 5:37

Okay. That's all plans or That's all supplemental plans.

SPEAKER_00 5:40

Supplemental plans, exactly. So when it comes to advantaged plans, again, because you have come out of that A and B system, now you're under a managed care plan, meaning it's managed by a private health insurance company, uh they now have this right to be able to say, no, we don't agree with doctor, or no, we want more medical records to prove that. So you've given that insurance company uh the right of final say so. And and and really, there is no way that um uh advantage plans uh could continue to exist if that right was taken away from them. They just no way. Because Medicare Advantage plans uh have they got to control the cost. Uh one of the biggest issues that you'll encounter, and I've had this happen many, many times, is uh uh let's say you're in a hospital and now you need to go to a skilled nursing facility for inpatient rehab. Uh so you can go there, but it's gonna have to be pre-approved, and oftentimes it is pre-approved, but the length of stay also has to be uh uh continue to be pre-approved. So while that care is going on, we have this continuing uh pre-authorization process. So people get sent home prematurely. Um Sadly, I got a letter from a lady not long ago from San Francisco, California. Her husband was sent home prematurely uh from an advantage plant. He was uh discharged uh and he passed away. And I mean, frankly, she blames the insurance company for uh his passing because she could not give adequate care to him. I had a person just recently that it's what was one of my live workshops who ran the Medicare advantage, uh, excuse me, ran the skilled nursing facilities. She had ran several of them. And uh she told me a story about a gentleman that was in one of their skilled nursing facilities on an advantage plan. He had had a stroke. After 13 days, the advantage company says, That's it, we'll cut him off. And we're not gonna cover it, and they said send him home. Well, they tried to do that. Problem is there was no home health care agency in that area that would take his advantage plan. He was single, had no one to take care of him. And I asked her this question at the end of the workshop. I said, Now, had he been on original Medicare A and B and had a supplemental plan, what's the average stay in your skilled nursing facility? She said between 47 to 48 days. Okay.

SPEAKER_02 7:47

So that's uh half and a half versus what's the what was the advantage average?

SPEAKER_00 7:51

Well, the advantage would typically be less than 20 days for sure. Now there's sometimes it's going to be longer, but average, and but his stay was 13 days after a stroke. And so uh when a person pays a premium for a Medicare supplemental plan, that's what they're getting. Okay, I chose to go with the plan G. Why? Because I didn't want to have to hassle with preauthorizations. And so many times uh those of you that are on uh supplemental plans, your neighbors may, you know, give you grief because they're paying nothing or because they can get to go to the gym for free and you don't get to do that. And I just want to remind you that one of the reasons we pay a premium, yeah, I have to I don't get to go to the gym for free, but I get to stay in the skilled nursing facility for 47 to 48 days versus being uh let loose in 13 days. Yeah. And so that's what matters. And I think that's really what our company is built upon to make sure not that you buy a submodal plan, but you understand that when you choose a plan, uh it comes a consequence.

SPEAKER_02 8:43

And it's gonna have an impact on your care, maybe not now, but maybe down the road. Exactly. Right. And the problem is people, you know, when you're coming off employer coverage, you're used to being able to change your insurance every year without an issue. You get on an advantage plan, something changes in your health. You're in unless you're in a just a couple of states, you're stuck on that advantage plan for the rest of your life, perhaps. So they're very, very big stakes to choosing right the first time.

SPEAKER_00 9:05

Trevor Burrus, Jr.: Yeah, and it doesn't make advantage plans bad. What it what it means is you, as the person on Medicare, you have to understand these things because when you go through some kind of serious health issue, you're gonna have to live with the consequences of the choice. And we just want people to be to be satisfied. And I I want you to know that if if we uh uh uh looked out for our best interest, we would not even talk about what we're discussing today. Why? Because uh when a person uh enrolls into an advantage plan, we as agents make double the commission. So it's in our our our and our best interest for you to take an advantage plan. However, uh we uh we know it may not be in your best interest, so we want to make sure that you understand the consequences. And that's one of the things, and I've been doing this now a long time, and it um uh stirs me up because uh agents oftentimes do not care enough about you like they should. They care more about what their paycheck looks like. Trevor Burrus, Jr.

SPEAKER_02 9:59

Well, but uh like take it up up a level. Most of your big call centers, those people that are filling up the advertisements all over, you know, all over the radio, all over the internet, all over TV, they these agents that they're not trained on supplement plans at all. They're they're brought in, they get licensed, they go through a you know 21-day class or whatever, and then they're they're contracted to sell Medicare advantage plans, and that's it. That's all the training they've had. So you call in, you know, expecting to get your full load of options, and all you're getting is advantage plan recommendations. Right. And so thankfully there's folks like us, and there's other, you know, us and other other people like us that are trying to shed some light on the other side of how all of this works. So we've got some interesting charts we want to go through produced by Kaiser Family Foundation, just the number of Medicare Advantage enrollees that are required to receive prior authorization broken down by the services. Okay, let's talk to uh Greg from Missouri. Greg, welcome to Medicare School Daily. How are you? I'm good, how are you? Good, what's going on?

SPEAKER_04 11:02

Oh, well, I just had a question. Uh when I first went on Medicare, I didn't opt for a prescription drug plan. And now that I've I have it, I have the uh an advantage plan. Okay. I have to pay four dollars a month from now on. Like I guess forever, right?

SPEAKER_02 11:23

So when did you start uh when did you first enroll in Medicare A and B?

SPEAKER_04 11:29

Um turned 65 in uh 24, October of 24.

SPEAKER_02 11:34

And what did you do what did you do for coverage since then? Before you got on this advantage plan.

SPEAKER_04 11:42

I didn't.

SPEAKER_02 11:43

You didn't do everything. You just had A and B that only Yeah, now you got a drug plan. Did you get a supplemental plan as well, or just the drug plan? Or you said you got an advantage plan.

SPEAKER_04 11:53

Yeah. Advantage plan.

SPEAKER_00 11:55

Yeah.

unknown 11:55

Yeah.

SPEAKER_00 11:56

And your question was, is it a lifetime penalty, Greg? And it is. Uh so what happens, uh you turned 65. When when was your like walking through the exact model? October. October. Okay, so what happened was uh this. I'll explain exactly what happened.

SPEAKER_04 12:10

So well um I didn't know anything about it. Sure. I just took A and D. And then I was on that for that was in our started in October, well, December, something like that. And then I came to one of your classes and learned more about it, and but it was after the enrollment period. Right. So I had to go the whole 2025 mostly with that.

SPEAKER_00 12:37

So your drug plan just started 1-1, 2026, is that correct? Your advantage plan? Yes. Okay, good.

SPEAKER_01 12:43

Yes. Yeah.

SPEAKER_00 12:44

So uh what happened is this uh once your birthday was in October, so starting in February of 2025, uh your your penalties um uh began, excuse me, um yeah, 2025, February 1. And so they're 1% uh uh per month um based upon the part D average plan, which is basically about 40 cents. So that's why you have a $4, it's basically 10 months that you went without a drug plan that you're eligible to have, well, actually 11 months. So the penalties began 2.1, went all the way through 12.1 of last year, uh so they're stopped. Uh and so that's uh what you'll have to pay now, of course, for the rest of your life, um, because you have a drug plan that's embedded within the advantage. So that's what happened. You have 11 months worth of penalty.

SPEAKER_04 13:29

Yeah. What is the what is the uh thought process behind penalizing somebody?

SPEAKER_00 13:37

Yes, sir. Well, and I and I don't think for a second this is what you did, but the thought behind it is this. Um a lot of people uh will not get a drug plan because they don't pay a premium or they whatever for whatever reason, and so they go without a drug plan, and then they have a serious illness and they need a very expensive medication. So some people don't get it because they're turning 65, they're healthy, don't see a need for it, don't want to spend any money for it, and so they'll delay it, and then they get you know some serious issue, cancer or you know, some kind of autoimmune uh autoimmune disorder, and now they want Medicare to uh give them a drug plan immediately and so that Medicare will cover the the expenses. So the penalty comes by by saying you better get it when you're first eligible at 65 or when you retire. And if you don't, you can still get one because you're eligible, but you're gonna pay a penalty, and you can't come in just when you want. You can only come in October 15th through December 7th. So that's the rationale behind it. And again, I don't think that was you, uh, but many people will not get a plan because they don't need it uh uh at the time they start Medicare and want it later. I'll give you a great example. I have clients, several right now, they're on a medication called Stellara. Stellara is an autoimmune disorder medication, Crohn's disease, cirratic arthritis, various things. Uh and that medication in full dosage right now is $33,000 a month. Now I have some clients on that amount, they're on $18,000 to $20,000 a month. And so someone has no issues, they'll get a drug plan, and all of a sudden they need Stellara, and now they're they they want a drug plan. And so Medicare says, okay, we'll cover it because we have to, but you can't add it until open enrollment season, and we're going to charge you a 1% penalty uh per month for every month you went without.

SPEAKER_01 15:17

For the rest of your life.

SPEAKER_00 15:18

Yeah, for the rest of your life.

SPEAKER_01 15:19

Yeah.

SPEAKER_00 15:19

So and I'm sorry that happened to you. I really am. But honestly, uh the I mean the four bucks, not a big deal. I'm glad you have a drug plan because if something happens to you, Greg, max out of pocket, $2,100. And that's really awesome.

SPEAKER_04 15:32

Okay. Well, yeah. Well, thank you.

SPEAKER_01 15:35

Okay. You're welcome. Hey, we appreciate you calling in. Well, any other questions you got?

SPEAKER_04 15:39

No, not really. Okay.

SPEAKER_01 15:41

Take care.

SPEAKER_04 15:42

Thank you. See you, sir. Bye. Bye.

SPEAKER_02 15:47

Okay, so Dad, what are the top five things that people get declined for or pre- they have to go through pre-authorizations for once you're on a Medicare Advantage plan?

SPEAKER_00 15:55

Okay, number one, any kind of uh advanced imaging uh that includes CAT scans, MRIs, and PET scans.

SPEAKER_02 16:03

Okay.

SPEAKER_00 16:03

Uh and so doctor orders it and insurance company has to approve it, and they're going to know why do you believe this is necessary. And so oftentimes those are are denied. Now what happens is doctor may provide additional information and then uh then they'll approve it. What's interesting, Josh, is that I think the number is about 70 percent or so of all uh preauthorizations that are denied uh if they're appealed, then they get approved. And that's kind of the frustrating part. Well, why why did why didn't you uh approve it uh the first time? Why did I have to wait an extra week or two weeks before we jump through the hoops of additional documentation? And that's why, honestly, uh sometimes you're gonna find out your doctor is not gonna take advantage of plans for this very reason. Because it's just more legwork for their extra house. Yeah, yeah. Yeah, I think I think the average the average doctor, just one doctor, has to uh spend uh on minimum 13 hours a week on pre-authorizations. That's the way it works. So and of course they're not gonna do it, they're gonna have to hire staff to do that. So it costs them money. And that's just one doc. And so you have a practice that has 10, 15, 20 docs. You can imagine the personnel that's required to make sure that uh those uh get approved, and when not approved, appealed.

SPEAKER_02 17:16

Yeah.

SPEAKER_00 17:16

Yeah. So it's very frustrating. Number two would be any kind of post-acute care, uh, which is basically skilled nursing facilities. So let's say you have a stroke or you uh have a hip replacement, or maybe you take a fallen injury, have an accident or something, you are more than likely going to go to the hospital and then uh they're gonna uh discharge you into a skilled nursing facility for intensive rehab. And when that happens, that's called post-acute care. It is absolutely the most expensive uh uh cost of care for all advantaged companies. This is something they have to control uh because it can break them. The average cost right now is about $550 a day for post-acute care. Uh and so the companies really try to control this. So what they do is uh they will um uh you know you you're in for a reason and they'll say, now the average time for skilled nursing for that particular injury or accident or whatever is going on is so many days, 18 days, 13 days, 15 days. And so regardless of the clinical evidence, uh many times they'll they'll just stop paying the bills. And I've seen it time and time and again. So that's the really the risk that you run. Now, it doesn't mean that's gonna happen to everyone, but it happens to plenty of people where they need to be in for a few extra days, and the uh your advantage plan says no, we're not gonna cover that. And so then there have to has to, you know, they're gonna discharge you to go home for home health care or something. So that's number two. Number three would be durable medical equipment. Uh durable medical equipment is uh equipment that it means durable, meaning it has a life expectancy of at least three years. Someone else can use it after you're done. And so these are expensive items, beds in the home, um, uh scooters, wheelchairs, walkers. Are diabetic supplies part of that? Yeah. No, diabetic supply problems or anything. You wouldn't call it that. It wouldn't be but it's still covered under Part B. So a lot of times we'll classify that under durable medical equipment. But uh it it's it just means multiple users. Okay. And so whatever that that bed has a life expensive of at least three years, durable medical equipment. So oxygen uh equipment, those kinds of things would be durable. Uh and so again, they're expensive. Uh and another reason there's a tremendous amount of um uh pre-authorizations is because uh durable medical equipment is is one of the greatest abuses uh within the Medicare system.

SPEAKER_02 19:31

Why is that? I've never really understood what I think.

SPEAKER_00 19:33

Well, because it's it's everything outpatient. I uh listen, I had I had one of my clients that um uh was on auction equipment for a for a while and he healed up, didn't need any more, and they still kept delivering auction to his house, all kinds of bottles, and he said, I don't need this. Why are you doing that? So they're getting billed for it. Exactly right. And so that durable medical equipment was abusing uh the Medicare system. That's just one patient. Can you imagine multiply it times millions? And that's why these insurance companies say, hey, we're gonna check this out. But sometimes people actually need it and that they still uh cause them some grief to make it.

SPEAKER_02 20:06

So get the bad people that make it hard for the phone.

SPEAKER_00 20:09

Yeah, very unfortunate. So durable medical equipment, number four, would be any kind of an outpatient surgery, uh knee replacements, uh excuse me, knee replacements, um, you know, gallbadder removal, all the list of outpatient procedures. Yeah. Yeah. And so what happens is that's gonna have to be pre-approved. And and many times they are going to approve what you need, but sometimes they don't. And it's that extra documentation, it's that that's delay and those denials that can be very, very frustrating. Okay. And then lastly, then uh this would be non-emergency uh transportation needs. Uh so if someone is in an emergency situation, that's gonna be covered, no questions asked. But if they need to move from uh the hospital to a skilled nursing facility or move around in some fashion, and I can understand how that could get abused as well. It sure can.

SPEAKER_02 20:57

For sure.

SPEAKER_00 20:58

Yeah, it can.

SPEAKER_02 20:58

So although advantage plans usually limit that to like 20 trips a year or something. Trevor Burrus, Jr.

SPEAKER_00 21:02

Yeah. And that would be that would be true. And that would be from your home to the doc's office or whatever. Exactly right. So those are your top five. Um so when you are on a vantage plan, you just have to understand these are the kind of things that you have to accept because it's going to happen.

SPEAKER_02 21:17

Trevor Burrus, Jr.: Okay, we've got an interesting chart here, which we'll we'll put up on the screen uh for those that are watching on YouTube. Share of Medicare Advantage enrollees required to receive pro authorization by service. So it looks like 99 percent of you will have if you're on a Medicare Advantage plan, we'll have uh prior authorizations for some of the things. So let's break it down. 99 percent durable medical equipment, 99 percent of folks will have uh prior authorization for school nursing, 98 percent for Part B drugs, inpatient hospital stays acute. What does that mean?

SPEAKER_00 21:47

Um That means they've been admitted. They had a heart attack.

SPEAKER_02 21:51

Yeah, they're they're admitted to the hospital. 96 percent, uh 93 percent for diagnostic procedures, labs, and tests, 93 percent for any uh psychiatric. Inpatient hospitals stay, 91% are going to need prior authorization for home health services. And then we've got kind of things that are in the 78 to 80 percent, which is uh hospitalizations, diabetic supplies, comprehensive dental services, opioid treatment, mental health, um, physical therapy, and speech language pathology. So if you're on physical therapy, 72 percent of you are gonna be required to receive prior authorization.

SPEAKER_00 22:26

And that will also require ongoing because they may approve five treatments, but maybe need 20. So after the five are done, then they're gonna have to go through that pre-authorization process again. One of the probably the most frustrating situations that people face, you you'll face on advantage plan is uh you also have a copay every time you go in. Trevor Burrus, Jr. On physical therapy. Exactly. So we have a knee replacement and we go home, home health care covers for what $20 for Usy, yeah, usually $40. Yeah. Every time you go in. So that's uh definitely a point of uh frustration.

SPEAKER_02 22:54

Uh this is interesting. Fifty-four percent of Medicare Advantage enrollees are required to receive prior authorization for a physician specialist. So go see a specialist. Well, and the reason you can't just go see a specialist and you're on a HMO. If you're on a Medicare supplement, I don't know. You just go see HBO. Like I want to see you. Do you take Medicare? If you do, go. That's right. And there will be a lot of people. No referral, no prior off.

SPEAKER_00 23:15

That's right. That the reason is because that's an HMO plan.

SPEAKER_02 23:17

Okay. Well, it's 54 percent of Medicare Advantage enroll Ace. But have you looked at look at this, look at this chart. The number of people that are in, I'm gonna scroll up a little bit. Um you know what, I'm in the wrong spot. Yeah. Well, whatever. That's right.

SPEAKER_00 23:35

Well, all I'm saying is that if you have a PPO plan, it's not gonna require a pre-authorization to see a specialist.

SPEAKER_02 23:41

It's not gonna require a referral.

SPEAKER_00 23:42

Exactly right. Um which I'm saying that that's really the pre-authorization. Exactly. That HMO plan, uh it can't you cannot see a specialist usually without the doc setting up that appointment.

SPEAKER_02 23:53

Trevor Burrus, Jr.: So you're saying with a PPO, there isn't there's no pre-auth to see a specialist. No, there's not.

SPEAKER_00 23:58

As long as they're in the network, you just call call them up and make an appointment.

SPEAKER_02 24:00

Trevor Burrus, Jr.: Hearing exams 54 percent, eye exams 51 percent, transportation 43 percent. The good thing is is your preventive services, only 7 percent, uh, require pre-authorization. So most of you can get your pre preventive services done. But beyond that, probably a good chance that that's gonna have to be uh you know authorized by the insurance carrier.

SPEAKER_00 24:20

Trevor Burrus, Jr.: So here's the point. When you talk to the and the average agent today that wants to sell you an advantage plan, the what they're gonna talk about is a little dental allowance, uh maybe some hearing aid coverage, gym membership. Uh and those things matter, but this is what matters most.

SPEAKER_01 24:33

Yeah.

SPEAKER_00 24:34

How is your Medicare going to work uh uh for you when you have cancer, when you have you know some kind of health issue? To me, that's more important than I get to go to the gym for free. Now, if I'm healthy and and stay that way, then that gym membership matters. But this really to me is the critical thing.

SPEAKER_02 24:51

Okay, let's talk to Teresa in California. Teresa, welcome to Medicare School Daily. What questions do you have for us? Oh, good morning. Good morning.

SPEAKER_03 25:00

How are you today?

SPEAKER_02 25:01

Doing well. Thanks for calling in.

SPEAKER_03 25:04

Great. And I'm talking to Marvin and Josh, right?

SPEAKER_02 25:08

You sure are. In the flesh, yeah.

SPEAKER_03 25:10

Okay. Fantastic. What a team. Um I am looking for the Social Security Earnings test. And basically as it re relates to housing as a condition of employment. And um, I need to know where I need to go back to work. I'm on social security and Medicare, and that's new. And I need to know if I should go for a higher amount that I'm qualified for or a lower amount where I trul need to try to be in that space, not to be in any landmines.

SPEAKER_00 25:48

Okay, so uh I would uh my impression or uh I g my thought is you are you're on social security disability, is that correct?

SPEAKER_03 25:57

I wish I was, but I'm just on social security.

SPEAKER_00 26:00

My bad. Okay, so uh you're just you're on regular Social Security. So let's go through it. What happens right now, this year, the most you can make without any consequences, Teresa, to your Social Security check is $24,480. That's an annual amount, and that is in wages. That's not rental income, investment income, nothing income other than wages. So if you make above $24,480 this year, then what's gonna happen? That's gonna, that's gonna there's gonna be consequences to your Social Security check. So let me ask you, from the from the from this point forward, do you think you're gonna this year you're gonna make above $24,480?

SPEAKER_03 26:37

Typically when I when I work or when I'm able to work, I make above ninety thousand. Okay. And so, but I but I could do that in a lower way and accept housing as a condition of employment, which means it's part of the wages. But they never count it.

SPEAKER_00 26:58

Well, that would be that would be awesome. Here's here's my point too, Teresa.

SPEAKER_02 27:01

Will they will they include any sort of numbers on your W 2? Because if so, that could count towards the earnings test. Or will it literally not show up on your W 2?

SPEAKER_00 27:14

It's just a benefit they provide that's not reported as income, is what Josh is saying.

SPEAKER_03 27:19

Yes, thank you, Josh. I but I think sometimes it is A and sometimes it is B.

SPEAKER_00 27:26

So Okay, Teresa. If you're gonna be able to above anything on the 24480, here's what you have to remember. For every two dollars above, they're gonna take a dollar, they're gonna take a dollar out of your check. So let's keep it really simple. Let now have you made any money thus far this year in wages?

SPEAKER_03 27:42

No.

SPEAKER_00 27:42

Nothing. Okay, so now we're we're starting here June 1, so we have seven months left. So uh you're basically gonna be at about, you know, if you're gonna be below three thousand dollars, you know, thirty two hundred dollars a month moving forward, it's not gonna be an issue because that's gonna be an annual amount. So you have zero so far, we have seven months left. So we take twenty-four, four eighty divided by seven, it's gonna be a little over three thousand dollars a month. And so if you think that's gonna happen, uh then then you're you are gonna be above the earnings test. Uh and you're gonna have to actually estimate that because what's gonna happen is they're going to they're gonna you you if you go back to work, you're gonna have to tell them because they're gonna say, okay, you're gonna be above by, let's say, six thousand dollars, and then they're gonna withhold some Social Security checks. Because if you don't let them know and you're above the earnings test, then they will go back and they will collect that money by withholding Social Security uh uh checks from you until you've paid them back. So my point is it is in your best interest to either stay below it or if you're gonna be above it, which I hope you make ninety grand for the rest of the year. Just know then that you have to let them know so they can recalculate your numbers for that for that amount that you're above the earnings test. Now, I'm gonna clarify something. Next year, that number is gonna change. Now you're gonna hit your full retirement age uh in May of 2027. So here's what's gonna happen. For January through April, next year, you're you're gonna be able to make sixty-five thousand hundred and sixty dollars in a four-month window. Uh it's an annual amount, but but but they don't prorate it by the month. You can make that in four months. So now we can make what, you know, uh $15,000 a month without any kind of bearing at all to your Social Security check. That's next year. So this year gonna be limited. Uh, but again, it's just so we have seven months remaining. Okay, so with that information, Teresa, what other questions do you have?

SPEAKER_03 29:35

Okay. Um I know that was a lot that no, um that's very actually very helpful. Thank you. Um it gives me a more of an idea about where I need to be because I think the the threshold for the California withholding and the taxes is 51, where you just really start getting taxed a lot. So um I'm gonna lose some this year. Do they actually give that back to me? The if it's two dollars above, I pay a dollar for every two dollars above, right?

SPEAKER_00 30:10

Yes.

SPEAKER_03 30:10

Does that come back to me in any way?

SPEAKER_00 30:12

It will, it will, but not in lump sum. What they do is once you hit your full retirement age, they'll recalculate that amount of money, uh, uh how many months that they withheld it, and then they will they will they will uh uh adjust your your your uh benefit moving forward. So the way I the way I describe it is they'll take that full amount and and it will be given uh back to you over time because they're gonna recalculate. So incrementally. Incrementally, they're gonna recalculate your for retirement age benefit based upon the money that they withheld. So let's say they withheld $8,000. I promise you, you're not gonna get a check for eight grand. They're gonna recalculate the number and you'll get that eight thousand dollars over time.

SPEAKER_03 30:54

Okay. And in terms of Medicare, um, is there anything I need to be aware of there or you know, are there any landlines there?

SPEAKER_00 31:03

Well, I think the issue would be if you're going to get benefits at work that are very attractive, uh then you may decide to get off Medicare. Uh you have to have A, but you don't have to have B. Meaning if you have a good group plan that's offered to you that's really better coverage, maybe better costs than your Medicare benefits, then you may want to consider uh coming off Medicare. Uh that would be the only landmine. Uh otherwise you just tell your employer, hey, I've got I've got Medicare and I've got you know great benefits. Usually employer provided plans, unless they're covered, you know, at like you know, 80 or 90 percent, are not better than Medicare. Okay, are you are you single, I'm assuming? Is that right? You single?

SPEAKER_03 31:44

I am, and I have the best plan because your representatives did it for me. Okay.

SPEAKER_00 31:50

Yeah. It's it's tough to be Medicare. Listen, hey, I I'm I I'm on Medicare and I have an employer plan available. Yeah. And I even have an IRM.

SPEAKER_02 31:58

Yeah, but it's nowhere as good as exactly right.

SPEAKER_00 32:00

Medicare is tons better. And we have a good plan for our employees, but Medicare is very good.

SPEAKER_02 32:05

I I wanted to just circle back real quick, uh, Teresa, on the uh household as a condition of employment. So here's here's kind of I've been kind of searching around on this. So if if the California employee housing is required on site and truly necessary for the job, it may be excludable and not count for the earnings test. Okay. However, if it's a perk or there's a housing allowance, optional lodging, discounted rent, or if it's going to be reported as a ta part of your taxable wages, that's probably going to count towards that earnings test.

SPEAKER_03 32:42

Good. Thank you. I I read a little bit about it, but it was a little bit murky to me. There seemed like there were some great areas when I was a little bit confused.

SPEAKER_02 32:52

Yeah. Well anything related to the government gets confusing.

SPEAKER_00 32:55

Yeah, I would ask your employer, hey, is this something you're gonna report if it is? I'd I'd count on. You're probably gonna it's gonna come into the earnings test. But if they don't report it, not issue.

SPEAKER_02 33:04

But if you're gonna go be a if you're gonna go be a cowgirl at a ranch and you gotta stay in the bunkhouse, then it probably it probably wouldn't be countable.

SPEAKER_03 33:12

Oh, I mean I could wear cowboy boots. Okay. All right. Um so I think that I have the answers to my questions.

SPEAKER_01 33:26

Um take take care, call Rack in if you have other questions. Appreciate you calling.

SPEAKER_02 33:32

Thanks.

SPEAKER_03 33:32

No, and thank you very much. Have a great day. Bye-bye.

SPEAKER_02 33:37

There are six things that Medicare will never cover. So if you're trying to get these things done, good luck. Uh, you're gonna have to be paying for them out of your pocket. On tomorrow's show, we're gonna be talking about what those six things are. So join us. Also, if you need help with Medicare planning, whether that is uh enrolling in a supplemental plan, comparing supplemental plans, getting an advantage plan, getting drug plan, our team is here and ready to help you. When you call in, you're going to be talking to someone that's been trained by my dad, Marvin. Uh, and they're able to help you. If you live in uh Maine or Michigan or uh New Hampshire or I don't know, I'm stuck up in the Northeast, California, wherever it is, in any of the 50 states, we are here ready and able to help you compare all of your options and figure out what plan is going to be right for your situation. Our services are free. There's no cost. So I encourage you to call in phone number to call into our office, and we're here every day from 7 a.m. to 7 p.m. Uh uh Central Time. Phone number is 800 782 6676 800 782 6676. We look forward to helping you. We'll see you tomorrow.