Medicare School Answer Hour
The team at MedicareSchool.com led by Marvin Musick and His son Josh Musick answers REAL Medicare questions from our callers, and help bring clarity to the VERY confusing Medicare System.
Medicare School Answer Hour
Should Prior-Authorizations Be Illegal?
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Prior authorization means your insurance company may require approval before certain care, tests, or medications are covered.
In theory, it’s meant to control costs and make sure care is necessary.
But in real life, it can delay treatment, frustrate doctors, and leave patients stuck waiting for answers.
Today on Medicare Answer Hour, Marvin and Josh are looking at different studies and articles about prior authorizations, the problems they can create, and whether they’ve gone too far.
Prior authorizations are something that you may have to deal with on Medicare if you choose a specific type of plan. Uh there's an article out that basically asks the question should prior authorizations be illegal? Now, if you don't know what a prior authorization is, is basically where an insurance company says, hey, that service that your doctor recommended you get, we're not going to cover it. And so there's ways to fight it, or maybe it's just going to be simply denied. So we're going to talk about pre-authorizations, whether or not they should be illegal, and what you can do about uh your situation if you do get a prior authorization. Welcome to the MedicareSchool.com answer hour. My name is Josh Music, and I'm here in the studio with my dad, my co-host, Marvin Music. And whether you're just starting Medicare, you're just starting Social Security, you're just now retiring and you have a question about your situation, you can call in and get all of your questions answered by calling 833-824-2004 Monday to Thursday. The Medicare School.com answer hour is here so you don't make a mistake. So you don't get caught in bad coverage that you do not understand and end up with financial surprises and bills down the road. So call in, get your questions answered, don't start Medicare confused and don't make a Medicare mistake. The phone number again is 833-824-2004, 11 a.m. Central Time, Monday through Thursday. So Dad, let's talk about pre-authorizations because these are a big deal. There's millions of these that happen every year.
SPEAKER_02I'm gonna explain prior authorizations and the impact they have upon people, and I'm gonna just give you a quick illustration. Someone has said that when we're going through a bad economy and your neighbor loses his home, that's a recession. But when you lose your home, that's a depression. Okay? And that's really the way it is with prior authorizations. You look at this when it's not affecting you, no big deal. But when you're the one impacted by a prior authorization, that's gonna be a big deal. Okay. And so there are millions and millions, I think what over 40 million prior authorizations uh that were denied last year, of course, across the board. And so this is certainly a problem. So I came across an article that I thought was very helpful. Uh uh, we I subscribe to a lot of things you do as well, Josh, of course, so we can kind of stay up to date. But this is put out by Becker's uh Payer Issues. And what they do is they, of course, report on a lot of things, health care. Uh, but they interviewed a guy, I'm just gonna give his name real quickly so you know kind of my source here. His name is Patrick Quigley, and he's the CEO of a company called Sidecar Health, a very innovative type of a company. I really like what they do. But uh he makes some comments as they interview him about um uh the impact of prior authorizations today. And so let's go through this just real quickly. I normally don't like to read a bunch of stuff, but I think what they're saying in this article is very, very helpful. Here's what they said earlier this year. Health insurance plans were required to officially begin publicly sharing how often they deny prior authorization request and how often those denials are overturned after they're appealed. Okay, now by the way, this was a voluntary pledge that was made by 50 different insurance companies because the government is trying to put pressure on them to demand it. Yeah, let's let us voluntarily uh make this pledge. So that's kind of what what this is all about. So this happened a year ago. And here's what this report says. And although all that data is now filtering out to the consumers, the numbers don't come close to telling the full story of just how big of a problem prior authorizations might be. The data doesn't tell consumers here's the problem, what kinds of services are being denied or why. It doesn't require insurers to report in a way that would make apples to apples comparisons possible, and it only includes percentages rather than actual counts. Furthermore, uh you have these you have seen these things, Josh, they call these insurance gold cards. And this is a kind of a program that the insurance companies come up with, but this article says that the insurer gold carding programs which exempt high-performing providers from prior authorization requirements, uh they skew the numbers even more. What the data shows is that denial rates vary widely, uh even among the nation's large insurers, and that most denials, get this, aren't getting appealed. And when they are, many are subsequently overturned. Okay, so people get this denial, and uh only about 4 percent of those people actually say, hey, I need this, I'm gonna appeal this. And whatever is information uh uh necessary to appeal it, only 4 percent do it. That's the problem. So well, you you're familiar with Kaiser Family Foundation, they put out a lot of good information. Uh there they chime in on this article and they say this. Uh KFS analysis of the first year of reported data, which is 2025, of course, found this that insurance companies uh deny between 12 and 18 percent of prior authorization request uh from Medicare Advantage plans. 12 to 18. Again, if you're not part of the 12 to 18, you know it's a recession. Yeah, exactly. But it's a big deal when you get it. Now, here's what happens that when patients appealed, 67 percent of those Medicare Advantage denials were overturned. In other words, the company uh changed their mind two out of three times. Uh what's the problem? Most people don't appeal. All right. Now listen to this. So we have one company called Centeen, uh, they overturned 93 percent of their appealed MA denials. So first first attempt, deny it. Yeah. Uh but 93 percent of those, they changed their mind. Now, uh to me, that's that that's broken. So well, just one more quick quote here. This is what Patrick says. He says we are creating massive amounts of waste in our system, and we're controlling cost within the system simply by denying care. And I think he is right about that. He says to me, it says to me the whole system is set up for an unsustainable outcome, and at some point it is going to have to break if it's not already broken. All right? Now, just one more thing here. This is uh actually a report put out by a group called the American Economic Liberties Project. And they actually published a brief. And what they do, Josh, is they call for an outright ban on prior authorizations as it currently exists. And their argument is this, that uh this gives companies the the the right to have this corporate care veto. I thought that's a great way to describe it. You have this private health insurance company that can veto what the doctor says. I had one doctor that I spoke to about this and he said about it. I go to medical school for four years, a specialist school another another four years, uh, and so I have all this education and someone is sitting in a cubicle uh that has the right to practice medicine. They don't take what I say is necessary, but rather what the insurance company is saying. And that's very frustrating. Anyway, so this brief go on uh went on to cite that listen to this, that the administrative burden on the physician workforce, because of prior authorization, listen to this, it's equivalent to 99,000 full-time physicians and practitioners at a cost of $30.27 billion annually. Okay. It's a real problem. Last thing. Here's what uh uh Mr. Quigley says to this. He says the right path is actually to stop and make prior authorizations illegal. I can tell you, Josh. If they did that, uh there would be no Medicare Advantage plans. Okay. I mean, at least that I can see. I mean, or or they're gonna have to well, because the only way they're gonna make their their profit margin is for them to have to say so and some of the care. Sure. Because why do they want them? Here's what the industry says. They say that prior authorization is a necessary a necessary check on rising costs. So that's the way they want to control it.
SPEAKER_00Yeah, but the if you look at what I mean, it it costs Medicare, original Medicare, because they pay these Medicare Advantage carriers to pay for somebody's health care, and it's costing them 10 or 15 percent more to have someone covered that way through Medicare Advantage versus if they just stay on original Medicare. Right? So the the the idea that that they're great at controlling cost is just not true. Trevor Burrus, Jr. No. They promised it in the beginning and it hasn't.
SPEAKER_02Trevor Burrus, Jr. Yeah, better costs, uh better care, and and it didn't happen. None of them happen. Trevor Burrus, I you think about it, son, it cost the it cost the government 10 to 15 percent more, and you look at the profits that these companies are getting, I mean billions every single quarter.
SPEAKER_00Well, I mean, it's kind of like you know, when when the government decided they were gonna start, you know, offering federal student loans, um, the the the universities their job was how do we get federal dollars? So we're gonna make up all these you know crazy degrees and all this stuff that now doesn't even help a lot of people because they need federal dollars. So when the when the federal dollar started paying these insurance cares, what are they gonna do? They're gonna come up with all these plans, thousands of Medicare Advanced Plans, try to put all this stuff in to get people on there so they can get a reimbursement from the government.
SPEAKER_02And then when you need care, they're gonna say, no, wait just a minute. Yeah. We want to we have to agree with that uh doctor's recommendation. And that's really what prior authorization is all about. I want to say this I want you to know that prior authorizations do not exist in every single service that you're gonna get. If you want to go see your primary care doctor, probably even a specialist usually, you're not gonna have to have prior authorization. But I can assure you, if you're gonna need an MRI, a CAT scan, PET scan, every single time, prior authorization is gonna be necessary. If you're gonna have a surgery, inpatient, outpatient, it's gonna have to be pre-approved as well.
SPEAKER_00And they might come back and say, hey, you don't get a hip replacement, we're gonna put a rod in.
SPEAKER_02Yeah. Or you get a knee replacement after nine months of therapy. I've seen that time and time again. But one of the saddest stories that I have about this uh uh was a lady and she wrote me from San Francisco and she told me a story about her husband, who was prematurely discharged from a skilled nursing facility, 74 years old, sent home for her to take care of him, and he passed away. Now, I'm not saying he passed away because of the insurance company, but I'll tell you right now, she blames him. And why? Because he should have stayed in that facility. And so post-acute care is very expensive. To have an extended stay has to have pre-approval. Insurance company would not approve it, and the skilled nursing facility said he's going home. Uh and uh anyway, those kind of things happen all the time.
SPEAKER_00Uh I don't know. I just don't know. I do know this. He passed away. A lot of people don't know that they can appeal it. I think one of the messages from this, you know, is if you get a denial, appeal it.
SPEAKER_02Yeah.
SPEAKER_00Well, you know, just don't take it as well, they're never going to cover it. That's right.
SPEAKER_02Give it a shot. Well, look at Centine, 93% of them are overturned. Two out of three uh across the board are overturned.
SPEAKER_05Yeah.
SPEAKER_02Uh so you know, and the doctor may have to give more information, uh, whatever is necessary, and some people don't go go uh through the work of doing that, but it's well worth it if that happens to you.
SPEAKER_00I do feel for doctors. I mean, the amount of work that they have to do uh in or after their day ends to do all of this stuff is crazy. Right. All the documentation, all the notes, all the the scribe. I mean, it's just and then deal with stuff like this where they already they're like, what this person needs it. Now I'd have to go to prove to some insurance company algorithm or somebody sitting in a cubicle somewhere that doesn't know the patient that they need this service. Yeah.
SPEAKER_02Well, Josh, then they have to go through ongoing reviews. So let's say they approve something and then the doctor continues on with care, and then there's something else that may need to be approved.
SPEAKER_00Yeah.
SPEAKER_02And they run the risk if they do it without getting pre-approved, they don't have to pay for it.
SPEAKER_00Yeah. You have more on that article? Okay. Sounds good.
SPEAKER_02Uh I could say this if you don't if you if you don't mind listening. Okay. And so here in my my my last quote from this gentleman, here's what he says. Why do we need prior authorizations at all? Instead, focus on creating transparency around decisions, around cost, around quality, so that people can naturally make better decisions because that's what's really going to lower the cost.
SPEAKER_00Okay, let's talk to Ken in Missouri. Ken, welcome to the Medicare School.com answer hour. What questions do you have for us?
SPEAKER_03Recently applied for Social Security benefits and for Medicare Part B. I I applied for Part A earlier this year. Do I need to wait until I receive confirmation from Medicare that my Part B is accepted before I buy a supplemental plan?
SPEAKER_02No, sir. Yeah, not at all. In fact, many many people actually apply for MedSup plans anywhere from three to six months prior to their B date going into effect. Uh some states allow a six, some some states three. So you know you're you're fine to do that. And also, Ken, if you're gonna use our company when you call in, uh we'll be able to go into that system to see exactly where that application is. Uh so be happy to do it. So if you're gonna use our our company, we'd be delighted, of course, to serve you. Uh I see you live in the in the Kansas City area. Um so uh we you can pick out your supplemental plan, you know, compare prices. Have you been looking at the drug plans as well yet or not?
SPEAKER_03I have. So I kind of I have drugs that are in tier one and tier two. So I have uh I've been looking at the different uh plans that are available in in the area.
SPEAKER_02Good, good. What what drug plan looks good for you so far, at least for this year?
SPEAKER_03Um probably is it the well, yeah, well careful.
SPEAKER_02Yeah, well care. Wellcare value script. Yeah, that's good.
SPEAKER_03Um but of course I'd want to get you know additional information before I you know decide that's a lot.
SPEAKER_02Whoever you talk with in our company, call in, uh they'll go through all that with you. By the way, that's the plan I'm on. That welfare value script is a good formulary, uh good coverage. And of course, we don't know what that plan will look like in 2027, but it will be years from uh 9-1 on, uh, you know, for uh four months anyways.
SPEAKER_00And then the premium could change. You'll get a notice of that probably towards the end of September, first part of October, saying, hey, your drug plan premium is whatever. It it still could be no cost. Is it a no-cost plan?
SPEAKER_02Uh no, nine dollars and sixty cents in Missouri.
SPEAKER_00It could change.
SPEAKER_02Yeah. There's some states at zero, but not Missouri. Uh so that would be really good. And then it sounds like to me, are you are you going, you moving uh let me see, are you leaning towards a G or an N plan? Have you decided yet?
SPEAKER_03Yeah. Okay. Yeah, those are the two options that I'm looking at. Um I just did want to compare um the premiums so I know what what they cover. Yeah. Um you're fine to do it now, Ken.
SPEAKER_02I would, since your B is going to affect 9-1, unless you already had some group plan or something that's going to cover you for September. I'd go ahead and take care of that, you know, ASAP.
SPEAKER_00And if if you call in, they can we can actually look you up in the Medicare system and see if you've been assigned a Medicare number yet. Well he has A. Oh, you have A. So you've got a Medicare number, then you're fine.
SPEAKER_02Yeah, you're just basically waiting on your your B approval and your and your card, but nothing's going to change. You know, your number will be the same, of course. Uh so yeah, you can take action right now, sir, if you want to.
unknownOkay.
SPEAKER_03I appreciate it.
SPEAKER_02Okay. All right. Hey, good good talking to you.
SPEAKER_00Thank you. Let's talk to Anna in Virginia. Anna, welcome to MedicareSchool.com answer hour. What questions do you have for us?
SPEAKER_06Um I have been on Medicare since this year, and over the past year I watched a lot of Marvin videos, which were very, very helpful. And I also use one of your brokers.
SPEAKER_00Awesome. Thank you. Your connection's a little smart either. Yeah, I am. Yeah, now we can hear you.
SPEAKER_06Okay. I had heard in one of the videos. Um if you have Medicare and a supplement, and I have plenty of feet. Um someone asked me what I have, and I was making an appointment for a visit. I said, I have Medicare and a supplement. And they said, Okay, well, we accept Medicare, but we do not accept that your supplement, that company. And I thought I had heard in a video that if they accept Medicare, they will accept your supplement. Yes. Supplement. So I I I you know, I'll just make an appointment with another doctor, but when I got the thing about the live, I thought, well, I'm gonna ask and get that clarified.
SPEAKER_02Sure. Well, hey, we appreciate your call today. And let me let me one of two things has happened. More than likely, the person that you spoke with was new to the business, and they have a list of advantage plans that are available to them that they'll take and not take. So even though you said supplement, many, many people, especially in reception teams, that do not understand the difference between a sub and advantage plan. So they go through the list, and uh what who who's the carrier you have right now on your supplemental plan? Who is it?
SPEAKER_06It's it's uh I want to say Health Spring or something. They're owned by Cygna. Exactly right.
SPEAKER_02Yeah, yeah, yeah. Well, actually, uh Healthspring owns Cigna. They bought them about a year ago. And so what's happened is they're they're looking up Healthspring and they're thinking it's an advantage plan. I'll almost guarantee you that's what's going on. Ninety-nine percent of the time, that's the problem. They will take your plan because if they take Medicare, they're going to take your supplemental plan. The other scenario that could happen, and again, this is very rare, I've seen it, and that's this. And that is that you could be going to a provider that is actually owned by the advantage company. So all they will take is advantage. Uh they won't take subs. And again, it's few and far between, but I have seen it happen. Okay, but more than likely that receptionist did not know what they're talking about. They're looking to the list to see what advantage plans they take, and you don't have that.
SPEAKER_00Do you mind sharing uh this provider's name? I was just gonna look them up.
SPEAKER_06Um it was it it's gastrointestinal specialists in in you know, mechanics over.
SPEAKER_02Yeah, guarantee if it's a specialist, uh the the it's the reception problem. Okay. It's it there are some primary care doctors that are owned now by advantage companies that that that's all they'll take is that you know, is that particular advantage company's plan. But there's no specialist that I've ever heard of uh that would uh be owned by the advantage company.
SPEAKER_06Well, I mean I tried to tell that lady if you take Medicare, you know, I've been told by an expert, you know.
SPEAKER_02Yeah, that's what they always say. But yeah, but that it's yeah, just say I do not have an advantage plan, I do not have any kind of network. Uh you take original Medicare, you take my submodal plan, set the appointment. Uh and I'm sorry you run that. If you talk to someone that that was a little bit more experienced, they would understand that. Or even what you could do is just be transferred to the building department. I don't know if you can get someone immediately, but but leave a message saying, you know, call me back, and and the building department can can set that person straight. Guarantee you.
SPEAKER_06Got it. All right. Well, I sure appreciate your time. We appreciate the call.
SPEAKER_02Nice to talk to you. Thanks for letting us serve you too. Okay, you too. Bye.
SPEAKER_00Okay, let's talk to Paul in Georgia. Paul, welcome to the MedicareSchool.com answer hour. What questions do you have for us?
SPEAKER_01Oh, hi, thanks. Uh thanks uh taking my call. So um I I went to a range of wellness visits with my doctor, and it's usually a nurse practitioner who does that. That that's who did it last year. She said, Well, uh, you've got to have an appointment with your doctor once a year. Uh, you know, that's a requirement. And I thought that that doesn't sound right. I mean, uh the wellness visit, as you know, it's very uh visit. It didn't sound like you'd need a doctor for that. So I thought, is that correct? Is it is it is am I required to see a doctor once a year? I mean, I'm on a supplement, I'm not on uh an advantage plan.
unknownYeah.
SPEAKER_02Yeah, that that is inaccurate. I've never heard that ever. So whoever you spoke with who just just you know confuse misinformation. Um, you're not required to use your annual wellness visit at all.
SPEAKER_00Uh now maybe the question whether or not you have to have the annual wellness visit or that a nurse practitioner can do it versus a doctor.
SPEAKER_01Yeah, that that's the job I got, right? I mean, uh I was setting up the appointment with with her, you know, for the actual wellness visit, but she said, Oh yeah, but that's you've got to book with the doctor as well as this visit, which I thought was kind of strange. So in other words, they're forcing me to do a paid visit with my doctor, which didn't sound right.
SPEAKER_00Yeah. Like in addition to the wellness, or that the wellness has to be done by a doctor, not a nurse practitioner.
SPEAKER_01I guess that's where I'm it sound like in it sounded like in addition.
SPEAKER_02Yeah, that's I I've never heard of that, Paul. So I I think let me ask you this. What do you what are you wanting to do? Are you wanting to go in for a wellness visit, or you just want to what what's what's the issue?
SPEAKER_01So I you know, I uh Yes, exactly. I I I don't mind doing the wellness visit. Like you say, you don't really get that much out of it, but I I do it anyway, just because you know it's not a bad thing to do. But uh I don't want to be forced to go and see the dots if I don't really need to.
SPEAKER_02So I would agree. Well, however they're gonna set that up, maybe it's it's possible in that system that Medicare requires that to you know to be billed specifically through the doctor. I've never heard that. I'm just trying to speculate here. Why would they say that if there's some reason?
SPEAKER_00This is on Medicare.gov. Yeah. Uh explicitly states that the visit is a con uh conversation-based appointment with your doctor or other healthcare provider. And then they list uh Medicare Part B covers the visit when performed by a physician, a nurse practitioner, a physician's assistant, or a certified clinical nurse specialist. Yeah. So I I think whoever's there doesn't know whoever told you that doesn't know what they're talking about. No. So that's right off Medicare.gov. You can just Google Medicare.gov yearly wellness visit and it says it all right. You see the rules on there.
SPEAKER_02You know what's sad, Paul, is that you know a lot of times these uh receptionists mean well, but they're not trained well. Yeah. Uh and they they they'll take one information from possibly a group plan and they want to apply that to Medicare or Medicare Advantage, and apply it to a you know a uh a Medicare supplemental plan. So um it's not it's not uncommon for us to hear well, we had a call today, same thing. Uh just misinformation from uh the receptionist at a doctor's office. So it does happen. So I try to correct them humbly as you can and tell them it doesn't work that way. Uh and then, you know, yes either send them to that same website and say, no, this is what I want, tell them what you want, and hopefully they will uh they will agree and get you on the schedule.
SPEAKER_01Okay. Yeah, and uh just a a second thing. Uh I called into the the program uh a few months ago. I don't know if you remember, but uh we'd had an issue with um the um the the threshold, the ermic threshold. You know, um basically I I uh I got I appealed it and it was successful. But my wife wasn't. And uh yeah, sure enough, they've they've never fixed it. So we had to call them recently. You know, they told us they'd taken care of it a few in the years and they haven't and they they never did. So somehow that got lost in the system for my wife. So let me answer.
SPEAKER_02Yeah, and you do f you you do you are married following a joint return? Is that correct? Yes.
SPEAKER_01Okay, okay.
SPEAKER_02Well then yeah, they should. And uh did the did they acknowledge that they received the paperwork?
SPEAKER_01Oh yeah. They said, yeah, we saw you you submitted the same paperwork for both people. So I mean Paul. I got mine straight away.
SPEAKER_02Yeah, I I'll bet you somebody else uh that was was responsible to process hers that didn't do yours, and that person dropped the ball. I I I truly have seen that multiple times when paperwork is just simply setting. You know, in someone's inbox, they didn't tend to it. Um so did they ask you to to reapply or they just said, hey, we'll take care of it?
SPEAKER_01No, said it takes care of it. I mean I I called into the uh you know the um national number. Yes, sir. Uh and I said, you know, I uh I heard that the local offices uh have limited um availability now for calling in, but you said no, in this particular case you will have to call the uh the local office to resolve it if it doesn't get resolved in the next next couple of weeks.
SPEAKER_02Okay, when's the last time you talked to them?
SPEAKER_01Um well the uh it was um several months ago. Probably when I called you guys, it was you know four or five months ago. That's been going on for every month, but that she hasn't had the uh return on it.
SPEAKER_02Hey, call them again, and by the way, I know they'll they'll retroactive it when they realize they've made the mistake. You should be able to get a refund on those ermors. Is that coming out of a social security check, or are you all having to pay that directly?
SPEAKER_01Yes, uh out of the social security check.
SPEAKER_02Yeah, they'll yeah, they'll they'll make they'll they'll make it right. They really will. Uh but I believe.
SPEAKER_01And I know it'll I know uh I know for a fact it'll be fine next year because you know uh both of us retired last year and uh uh we were well below the threshold last year. So it'll automatically fix in January. But uh obviously.
SPEAKER_00No sense in wasting the money for this year though.
SPEAKER_02Yeah, exactly right. What is the squeaky wheel gets in Greece? Yeah. Well, he can, uh, but if he's dealing with a local office, if you have talked to them, you know, you can just call them again. Hopefully you have their local number and say, hey, we're still waiting on that correction. Where do we stand? What's the status of that? Uh has somebody pulled it up? Because you'll you know what's interesting, Paul, guarantee you. If someone will pull that up, they they can make that correction on the spot. They really, really can. Yeah. So I'd I'd I'd be bugging them if it were me. So uh sorry that hadn't just happened.
SPEAKER_01And a shout out to your team. I mean, recently we we swapped providers for the supplements from United Healthcare to HealthSpring, and they say there's a bundle. I mean, fortunately, both my wife and I passed the underwriting questions. So good. It saved, you know, fifty or sixty dollars each per month. It was it was a lot. That's good. That's great.
SPEAKER_02Substantial. Hey, anytime we can help you, sir, we're here for you. Okay.
SPEAKER_00Money. Thanks. Okay, thanks. Yeah, good to good talk to you, Dave. If you're in the same situation as Paul, where you are on a maybe a supplemental plan that's gone up in price, you can call into our office and shop those prices. You'll have to answer some health questions, but there may be an opportunity for you to save some money. The phone number to call in to our office is 800-782-6676. 800-782-6676. And when you call in, they'll just lay the options side by side. There's no pressure, um, there's no cost. Uh, just try to help you save some money.
SPEAKER_02Yeah, now I want to add to this, not only did he save 50 to 60 hours a piece, but now they got to reset the clock.
SPEAKER_00Yeah.
SPEAKER_02Uh they've been in their group for a few years. That group gets smaller, people pass away, people change plans. So that's the benefit of uh switching those plans. Not only just save monthly premium, but now you're probably gonna be in a larger block, which gives you the healthier people. Exactly right. Healthier people uh could be more stable in the future as well.
SPEAKER_00Okay, let's talk to Jeff in Maryland. Jeff, welcome to the Medicare School.com answer hour. What questions do you have for us?
SPEAKER_04Hi, Josh. Um, yeah, a quick question, and I'm gonna thank you and especially your dad. He's right here. I have followed him since I turned 62 and retired. And he has helped me tremendous, and now I'm getting ready to go on Medicare. So he's gonna help me again. Uh my question is, Josh. Um right now I called my employer, and I have I'm a retiree for the state of Maryland. They are taking, of course, you know, when you turn 55, I have to get off their prescription plan and go to part D, Maryland Gun. Yes. And then they're also taking health insurance and um dental insurance out of my check. Now I called them because I wanted to make sure I said I want to get a supplement plan, either N or G. And they said, Well, you can do that, uh, but you really don't have to cancel your insurance. And I said, Well, what's the use of having three insurances? Because I'm gonna have my premium, I'm gonna have to pay for the G or the N, and then I have to, and then I have to pay the they're still gonna take the uh health insurance out of there. And if if the payer if uh Medicare becomes the first, and then the second, if I keep them, they would pay the rest of it, and I asked them, I said, Well, what about those six gaps? And she didn't have an answer for me, so I think that they're not uh that my insurance will not pay for them six gaps.
SPEAKER_02Hey Jeff, let me ask you a question. Um, are you confident, sir, that um uh that group plan, if you if you take the retiree plan, uh are you confident that it will not be an advantage plan? I mean you stay with the state almost always those plans now are advantage plans. Have they have they clarified that for you? Uh well it's through United Healthcare. Yep, guarantee you it's gonna be an advantage plan. Uh almost always, right? Yeah. Um that's again, I could be wrong, but but the look you you gotta find that out. Number two, what does it cost you, Jeff, to be on uh that emp that uh retiree plan? What's the premium you'll pay out of your out of your retirement check? Uh $91 a month. How much? $91 a month. Yeah, $91 a month. Okay. Well, I'll almost guarantee you that I I'll guarantee you that's going to be an advantage plan. Uh truly, 90 to 95% of all companies that offer retiree plans are now advantage plans. It's in their best, their their financial interest to do it, not necessarily in yours, but you need to find that out for sure. And so uh here's my my next question for you, Jeff. If you were uh to keep that insurance, uh can you separate the medical from the dental? Or is it just all one package?
SPEAKER_04They're they're saying that if I want to get rid of the health, I can keep my dental. Okay, did they give you a premium on that, sir?
SPEAKER_02Uh, it would still be what I'm paying now for dental, $15 a month. Okay, okay, that sounds good. And that's that's excellent. So, what I would like to see you do, number one, you really do need to verify what kind of coverage it is. So let's find out whether that's that's gonna be secondary to Medicare, because I doubt it's gonna be a supplemental G or N, but is it gonna be second to Medicare? How's that gonna cover? And you ask the right question, how's it how's it gonna cover the gaps? And clearly that person did not know. But let's find that out, and then I think you're gonna have real peace of mind knowing what your next step is going to be. I would say probably it's gonna be uh you're gonna you're gonna you're gonna cancel that, you're gonna keep your dental envision. If they'll allow you that keep that in place, let that come out of your check and just get a standardized uh Medicare Suminal Plan, you know, G or M, whatever you decide upon.
SPEAKER_04Okay? That's what that that's what I'm thinking, Marvin. That's exactly what I'm thinking. Okay, good. Oh, one other question, if I could. Yes, sir. Uh my wife is drawing, uh, she's 60 and she's drawing widow uh social security. She also got denied for social SSI disability, but she went and uh she has lawyers working on the case. Yes, sir. Now I heard can she get both checks, widow and disability, once she is approved?
SPEAKER_02No, no, no, she's not gonna whatever whatever would be the greatest amount available to her is what they're gonna give her. It can't be both. You can only receive one type of social security benefit. So if disability payments end up being more, uh they'll turn off the uh survivor benefit and um uh give her disability. Now let me just say tell you what's gonna happen. So once if she let's say she she does get approved from the date that they say it's approved, and sometimes they backdate it, Jeff, they may backdate it six months, but whatever that official date of SSDI is, uh then on the 25th month, then she's gonna be automatically enrolled into Medicare A and B. So if she does get that overturned, I know they they denied it, but if the lawyers can help, uh then twenty-five months later her Medicare A and B will begin regardless of her age.
SPEAKER_04Uh uh Okay. Okay.
SPEAKER_02That's the way it works. Can you say that again? Yes, sir, I will. I was saying that uh once if she does get approved for SSDI, whatever date that is, uh on the twenty-fifth month after that date, uh then her Medicare A and B will go effective. Okay, so you have to be receiving benefits for two years, and then the twenty-fifth month your Medicare starts, regardless of how old you are. Hey Jeff, there's people that are in Medicare that are 50 or you know, you know, 37 or you know, 61 uh like her, uh, but it's on the 25th month. So Medicare does not begin immediately for anyone other than people that have kidney failure or Lugarig's disease. They qualify for immediate Medicare, but everyone else that's on disability has to wait until that twenty-fifth month.
SPEAKER_04Okay. Okay, okay all right.
SPEAKER_02So that's the way it's gonna work.
SPEAKER_04And and then and then after the twenty-fifth month, if if she's approved and goes on uh then she can uh get a supplemental plan.
SPEAKER_02Maybe, maybe. Let me explain why. Because most states uh you cannot get supplemental plans uh if you're under sixty-five. So she may have to take she may have to take an advantage, but that's all right, because then what what happens once she does hit sixty-five, then she she can get off the advantage and get a Medicare supplemental plan. Okay, and that's that that's the federal law. Now, as she approaches this, we'll we'll see what Maryland's doing at that time because these states change the rules from time to time. But right now, as it sits, uh the majority of people who are on disability cannot get supplemental plans uh at 62 or 47, but they can when they turn 65.
SPEAKER_04Well, right now she has blue I think she has blue clock cross and blue shield. Can she stay on that plan until she turns 65?
SPEAKER_02Yeah, maybe. Is that is that was that a uh previous uh like was that her ex-spouse's uh plan? Is that how she how'd she have that insurance? How'd that come about? I think when you have uh when you're below a certain income or something. Okay, is it is it come some kind of a Medicaid plan?
SPEAKER_04I'm not sure. Okay, I'm not sure anyway.
SPEAKER_02So here's the point. Not knowing for sure the source of that insurance, but you can always call them and say, hey, will this will this get me to 65 or will this get me to you know to Medicare uh and find find that out? Uh because there are some plans that do, Jeff. Um I d I just don't know the source of it. Okay, where in other words, where did it originate? Let's find that out. So if it's if it's some kind of Medicaid, then yeah, as long as her income stays below the limits, then that should continue on. But you need to find that out as well. And then Jeff, once you have the answer to these questions, please call us back. We'd love to talk to you further about this.
SPEAKER_04Oh, yeah, I I'm gonna call one of your agents because you're a very trustworthy man. Yeah. And I know I know that you're pastor. I know I know your pastor. And that that helps too. Not a bad thing.
SPEAKER_02Yeah, yes, sir. Well, hey, we appreciate talking to serve you, sir, and uh we'll always we'll always do your right. So let us know what we can do next, okay? Okay, thanks, Marvin. Thank you, Jeff.
SPEAKER_00Good talk to you. Thank you. Take care. Okay, Gary, uh DC area called in a couple minutes ago, but had to go, but he left his question, so let's get it answered. Uh he is Medicare age, and he hears that Medicare goes back six months. Uh so he wants to understand that. He's heard us talk about like, you know, they backdate at six months. Um, and then what impact does does that have to an HSA? And then he also wants to know why someone would fill out a SSA 44 form. Okay. And how do yeah.
SPEAKER_02All right, did he by chance give us his date of birth?
SPEAKER_00He uh no, nope. Okay. So but he said he has Medicare age.
SPEAKER_02Okay, Medicare age. So let's um boy, let's go.
SPEAKER_00Assuming he's 67, whatever. Okay. I mean he's he's must be if there's Okay.
SPEAKER_02Okay, very good. So let's assume that 67. So uh uh in this scenario, we're gonna say he has done nothing at all with Medicare, doesn't have A, doesn't have B, and the reason is because he probably is contributing to a health savings account. And so what happens is this let's say that um uh someone wants to start Medicare in September. That's the that's their desired month. Uh normally when someone applies for Medicare, they're gonna apply two or three months in advance, right? So if they want to start in September, they probably started an application in June or July to have a September start date. So when we apply for Medicare, uh Medicare is going to backdate the A date from the date we apply. Not when we want to start, it's when we apply. So if I applied in June, they're gonna backdate six months. If I applied in July, from that date, they're gonna backdate six months. Now, as they backdate, they will never backdate uh prior to 65, but they will backdate six months, so whatever comes first, uh six months or my sixty-fifth birth month. So that's the one.
SPEAKER_00Part A doesn't cost anything. Exactly. So there's no expense related to that. Exactly right. And then they would start Part B when you tell them. Yeah, you pick the date, exactly right.
SPEAKER_02Yeah, you get to pick your B date, but A date is determined by backdating. But again, when they backdate, we know they're not going to go to you know 64 and nine months. They're gonna go to 65 or six months. And so then the why that's relevant is because once that A date is established, from that date moving forward, you can no longer put any money into your HSA. And so no contributions to go in once we have Medicare A. So up to up to that month, you can uh fully fund it. Now, a lot of people think uh let's say I'm gonna start my B date in July, then I'll put my whole year's amount of HSA money in. That's not good. Yeah, because you have to prorate that. So you take the max contribution, uh, which for an individual this year is about $4,500, divide that by 12 uh so you could put that much money on a monthly basis. So if my A date starts in July, that means from January to June, I could have maxed out on my HSA no problems. After that, I'm gonna have problems because I'm now overfunding my HSA.
SPEAKER_00Okay. So it's a monthly amount. Monthly amount to do the whole AM.
SPEAKER_02That's right. It is totally prorate. I think there's one is there one exception to this. Well, that would be this. Let's just keep it simple. Let's say that that uh I am I am employed, uh, I don't have A or B, I can still contribute to my HSA. But let's say my wife uh was already on Social Security, there she she therefore she took A, but she didn't take B because she's covered by my plan. So the spouse who uh it has A only, covered by group plan, covered. But it's an HSA. In other words, now I can make a family contribution, though she has A, she's covered by my group plan. So that's the little nuance that Medicare uh and Social Security will allow. Trevor Burrus, Jr.
SPEAKER_00So is it is it truthful or fair or correct to say if you can't contribute to an HSA uh once you have Part A, unless it's your spouse's HSA, and then they can contribute the family amount.
SPEAKER_02Exactly right. And and you have to be covered by that group plan. Is that correct? That's the exception. Because Medicare knows it's gonna happen.
SPEAKER_00So if it's their employment, you're fine. Their employment, their group plan, they're on it too. Family amount, go ahead and contribute. No penalties, you can't, you know, there's no restrictions.
SPEAKER_02But the employee couldn't have A. It is the spouse of the employee that can have A only.
SPEAKER_00Yeah, that's that's interesting. Okay, so then he asks his next question was why would someone use an SSA 44? Right. Well, that's the IRMA form. So I can talk about that for a minute. So an IRMA stands for income-related monthly adjustment amount. That's a big term. We just call it IRMA. But basically, it is a surcharge on your part B and your Part D if uh you make over the threshold. Okay, so the threshold in terms of income if you file single is $109,000. If you file married, that's $218,000. So then there's some different levels. Um this is basically a tax, right? So if you're over $109, you're gonna pay an additional amount for your part B, you're gonna pay an additional amount for your part D as in drug. So there's ways to appeal that though. Uh, in order to appeal that, the most common thing is, hey, I used to make that much money, I don't make that anymore because I've retired. Um, I've either fully retired or I've partially retired, and now my income is below the threshold. Um, and so you would fill out this SSA 44 form, you'd put in that you had a work stoppage or a work reduction, you'd put in the date of that event, and then you'd tell Social Security, this is what I plan to make. Like this is probably what I'll make as long as you're below those thresholds, then they will drop that income-related monthly adjustment amount off. And so uh if you have received one of these letters because you just applied for Medicare, or if you're um uh a lot of people get these in December because the way they calculate it is they actually go back two years, right? So 2026 IRMAs are based upon 2024 income. And if you've retired since then, you can appeal it using this SSA 44.
SPEAKER_02I mean this, Josh. So what happens on the appeal, what you're doing is we know they're looking back two years. Yeah. And so if you had a life-changing event last year or this year, you can say, stop looking at 2024. I retired in 25, or I retired in 26, or I got married, or there's a death, or there's a divorce, but a life-changing event. So you're just saying to them, don't look back two years. I've had a qualifying life-changing event that affected my income. I want to give you new numbers. And then so the IRMAS thing either can be eliminated entirely or go down a step. Sometimes people can't fully get out of ERMAS, but they can reduce the IRMA. Now, if you're our client, we'll help you with all of this. It does happen. So I just want to add that.
SPEAKER_00You don't have to navigate it alone. If you work with us on your plans, we'll be happy to help you navigate that. Make sure you don't pay anything extra. That's always the goal. Of course, we've all heard of Good Rx. And one of the questions you may have is should I use Good RX or should I use a Medicare drug plan? And there's specific situations where we would actually recommend you use Good RX, not necessarily in place of a drug plan, but to complement it. So on Monday, you're gonna learn how we would tell you to approach uh Good RX versus Medicare drug plans and how to use them together. We'll see you then.