Various Scenarios That Affect Coverage Transcript

Steve Sedahl  00:00

Welcome into Secure Money Health Radio with Lisa Lauro. Coming up the Secure Money Health Radio and Lisa and I will tackle Medicare what if, crossover scenario and more coming right up.

 

Speaker 1  00:14

It’s time to secure all your health care needs, and we will really simplify the process. Welcome to Secure Health with Lisa Lauro.

 

Steve Sedahl  00:27

Hey, welcome in everyone to Secure Money Health Radio where Medicare matters. Lisa Lauro is here as always. Hey, Lisa, how’s it going?

Lisa Lauro  00:34

I’m doing well. How are you doing?

 

Steve Sedahl  00:36

Very, very well. Thanks. I think we’ve, we’ve got a lot to talk about. I mean, you know, because I talk to people, and it’s my wife, actually. So how can you talk about Medicare for that long? I said you’d be surprised how deep, how, how sort of convoluted things can become. It’s just about clearing it up. It’s just about making it make sense.

 

Lisa Lauro  00:53

Exactly. There’s so much to it. And you know, I, you and I, we tackle a couple different topics each week, and hopefully the listeners are able to make more sense of it with these shows you know, because you know each little nugget matters, right?

 

Steve Sedahl  01:10

Sure, absolutely sure. And let’s mention your book. It’s called the well, it’s called The Ultimate Medicare Book, Simplifying Medicare So You Can Make Confident and Informed Decisions. But you can find that book now at medicaresimpleguide.com. medicaresimpleguide.com. Go to that website, sign up, get the book. Lisa will send it right to you. And you know, it’s almost like getting a golden ticket, because it’s in a gold envelope.

 

Lisa Lauro  01:34

Gold envelope. You can’t miss it, right?

 

Steve Sedahl  01:38

No, you really can’t. All right, so let’s jump into here. So, what we’ve done is we’ve got some kind of scenarios, and so Medicare, after a major illness, which, you know, here’s a couple recently diagnosed with cancer. They are, one of them is now needing expensive ongoing treatments. How well does Medicare actually cover major illnesses? That’s a good question,

 

Lisa Lauro  01:58

It is, and it’s something actually I just had to talk about with a with a client yesterday. So basically, Medicare, you’ve got your A and your B, and then hopefully you’ve paired it with either an Advantage plan or a Medigap Supplement plan. And those two supplemental-type plans are going to actually cover you differently, so we can kind of break them down one by one, if that’s okay, sure, because I think it’ll make sense that way. So, let’s say you have Medicare and an Advantage plan. Okay, the inpatient hospital stay, if you had to go into the hospital, is going to be covered by your Part A, and then the out, any outpatient treatment would be covered by Part B. This would include doctor’s visits, outpatient surgeries, and then any IV chemotherapies are done through Part B. However, on an Advantage plan, that part B is going to cover you 80% you’re going to be on the hook for 20% of that treatment on an Advantage plan. Now, the Advantage plans have this max out of pocket. So fortunately, it’s not a runaway train of expenses, because whatever your Advantage plan max out of pocket is, is the most that you would pay each year right before and it’ll it resets every January. How this differs from a Medigap Supplement plan is that the Plan G and Plan N of Medigap plans are going to cover the 20% so A and B will cover 80% and your Medigap plan is going to cover the 20% and virtually, you’re not going to have to pay anything, if you’ve absorbed the $257 annual deductible.

 

Steve Sedahl  03:56

Okay, wow, that seems like it, uh, you know, that’s something that, really we should talk about. I mean, I obviously you do when people are signing up for Medicare, those are the kinds of questions that that maybe even people don’t think about, because I didn’t, When you look at it this way, yeah, it’s, it’s different. It makes, it gives you pause,

 

Lisa Lauro  04:13

Yeah. Now Plan N does have some copays, so you might have to pay a $20 copay. That might be, you know, on Plan N, where Plan G doesn’t have copays, but really that would be like the most, which is huge, if you think about that. So, there are a couple really big areas where the Medigap and the Advantage plans differ in terms of costs that you might incur depending on your health, and this is one of them. Okay, good to know. Most people don’t know that.

 

Steve Sedahl  04:45

Right. Well, I didn’t, and I’m sitting here talking with you. It’s like, 724-293-6653. 724-293-6653, obviously, could you get the clarity? I mean, I’m a guy on Medicare, we know that, and so, yeah, it gives me it gives me pause.

 

Lisa Lauro  04:59

Sure, yeah, yeah. Something to think about.

 

Steve Sedahl  05:02

All right, let’s move on. I like this question too. We’re talking about remarrying later in life, so if you’re on Medicare. So, here’s a couple, both in their late 60s, both on Medicare, getting married. And so how does remarriage affect Medicare coverage? Or does it?

 

Lisa Lauro  05:16

So it is going to affect the Part B premium, Part B premium, right? Because if you are, you know, remember your Part B premium is based on your modified adjusted gross income. It’s a two year look back. So, this year in 25, they’re looking at your taxes of 2023 but when you get married, or, let’s say, remarried, right? And which is wonderful, right? I love hearing about stories like this, but when you get remarried, that is a life-changing event. And so now you are no longer filing your taxes as a single person, but now as joint and married, okay? And so, it would, that would actually affect your premium. And then, you know, it comes down to this year’s chart. You know, the, if single filers, if their modified adjusted gross income is $106,000 or less, they’re in the standard range of $185 and anything above that would, they would get an IRMAA charge. And then, if you married, if you’re married and filing jointly, $212,000 or less is, falls into that standard range. And then, of $185, and anything above that would incur an IRMAA charge. So, I guess it depends on where, where they are, if, if they’re in the standard range as a single person, and then jointly, they still fall in that $212,000 or less, then they’re still in the standard range, and it really didn’t affect their premium, right? But if they’re in a higher category, then their premium may be affected, because now they’re subjected to Income Related Monthly Adjustment Amounts: that IRMAA tax.

 

Steve Sedahl  06:59

So again, but this is a situation where, if somebody was getting remarried, let’s say they were working over at Secure Money Advisors and were going to do that, they could just come to see you and just work through this whole thing, because that, I mean, obviously there’s a lot going on there.

 

Lisa Lauro  07:12

Right, right. There is a lot. And I think, you know, that’s exactly the most important part here, is that, you know, we work directly with Secure Money Advisors. That’s our parent company. And you know, it’s such a nice thing to be able to walk across the parking lot here and go see the advisor, because we work hand in hand. And so, in these particular situations, it’s something where you may want to reach out to your to your financial person, and have them walk you through it and go over, you know, plans, tax implications that you might incur being remarried and in, that even goes for retirement too. There’s, there are tax implications in retirement if you don’t plan properly. And that’s, planning ahead is the key, right? So, you know, Secure Money Advisors. They don’t charge for, they don’t charge for a visit over there for (for a consult) yeah, and so, you know, if that’s if this speaks to you, I highly suggest that you talk to, yeah, come on in. Come on in. Give them a call and then collectively, we can work together on it.

 

Steve Sedahl  08:21

All right, fair enough. 724-293-6653, is the number. So, this one is this kind of gets into an area that people are very concerned about. Here’s a couple – rather age in place than move into a nursing home. Well, who wouldn’t? So, what will Medicare actually pay when it comes to in home care? And how should we plan, I mean, realistically for home health care costs with Medicare?

 

Lisa Lauro  08:44

Yeah, this is a little tricky, yeah. So Original Medicare and Medicare Advantage plans, specifically, they do cover some home health services, but only under specific conditions. And so, in order to qualify, you must be under a doctor’s care, and have a plan of care that’s regularly reviewed. So this, you have to, you know, constantly be reviewed by your doctor and they’re the ones that are going to write the script for you to get some home health care. They must, you must, the doctor must certify that you are home bound. Okay, so that’s one of the qualifiers, um, and that means that, you know, leaving your home is difficult or requires help, and then you need intermittent skilled nursing care or therapy services like a physical therapy, speech therapy or occupational therapy. So those are the pre qualifiers. But one thing to make mention of here, this is considered home health services. This is not considered or equal to that which you would get at a nursing home. Okay, all right,

 

Steve Sedahl  09:51

Well most of us want to stay home.

 

Lisa Lauro  09:54

Yeah, so you can stay home, and these are folks that are going to come into the house, but according to your health, they’re just going to be able to stay for a couple of hours, check on you, check your vitals, maybe organize your prescriptions, things like that. But they’re not, they’re really not there, it’s different from nursing home care that you would receive.

 

Steve Sedahl  10:14

Sure, or nursing home or nursing care at home, I mean, to have –

 

Lisa Lauro  10:18

Or nursing care at home, right. Right, which, which Medicare doesn’t cover, right.

 

Steve Sedahl  10:22

All right. Let’s see. We got time for one more well, quick one here. We’ll talk about Medicare, drug costs and inflation, because inflation seems to be affecting everything. The good news here is we were talking before the show that because of the Inflation Reduction Act, some good news from comes from that,

 

Lisa Lauro  10:38

Right, right. So the Inflation Reduction Act has been rolling out slowly in different phases over the last couple of years and so, you know, in 2025 this past January, they put a cap on medications, which is, is huge, because now so long as the medication is on the drug plan formulary, their list, they’re going to be capped at $2,000 but better yet, next year, for 2026 there is a list of roughly 10 medications that are very common, medications for blood pressure, for diabetes, for all sorts of different things, and they’re very costly. And those 10 drugs, now Medicare is able to negotiate cheaper prices for and hopefully that is going to reduce the cost for some folks, a lot of these, like the Ozempic, the Xarelto Farsega, those do not have a generic version here, although I did read yesterday that Xarelto, starting next year, is going to be available in the US as a, with a generic version of it. So that’s good news, but, but these 10 medications are going to hopefully be a lot cheaper, way more affordable for folks moving forward after January of 2026, due to that Inflation Reduction Act.

 

Steve Sedahl  12:07

Well, good news. That’s a great way to end this segment. Give us a call. 724-293-6653, and talk with Lisa. Come on in and get yourself, you know Medicare knowledge. That’s what we’re talking about here. We’re going to take a quick break. We’ll come right back and continue on Secure Money Health Radio with Lisa Lauro where, where Medicare matters.

We are back on Secure Money Health Radio where Medicare matters. Lisa Lauro is here. My name’s Steve Sedahl. We have been talking about, well, a very, I mean, a lot of things, because Medicare is, is a, it’s like an ever evolving something, because it’s always changing. There’s always something going on, and it’s important to keep up. And we count on you for that.

 

Lisa Lauro  12:55

Right, right. It’s important for me to keep up, isn’t it? Yes, but you’re right. There’s so many things that are constantly changing and evolving, some for the good, some for not so good. But we try our best to keep up to speed on the latest and greatest of the Medicare news here.

 

Steve Sedahl  13:15

All right. Let’s talk. Let’s jump in. Can I use Medicare to cover medical care while traveling above, abroad. I mean, it’s getting to be vacation season. I know folks are planning to go to Europe and you know all of that. How, if we’re on Medicare, what do we need to know?

 

Lisa Lauro  13:30

Yeah, Medicare generally does not cover medical care outside of the United States. And that is your original Medicare, Part A and Part B, okay, but there are some exceptions. So let me go through those exceptions with you. Emergency Care in Canada, if you’re traveling directly between Alaska and another US state is covered. Emergency hospital stays, so if a foreign hospital is closer than a US one, then it would be covered. Cruise ship medical care if within six hours of a US port. So, there’s a lot of weird ones, right? Like, these are just so, the rules on these,

 

Steve Sedahl  14:11

Like, how do we know if you’re six hours? I mean, how does, how does that determined?

 

Lisa Lauro  14:14

I know, I know, and that’s why I’ve said it before in previous shows, and I and, you know, I talk to my clients about it when, when you’re on a cruise ship, what I’ve heard, I don’t have firsthand experience of this, but what I’ve heard is that when you go to the infirmary there on the cruise ship, a), it’s expensive, and b), again, when you’re in international waters, it’s like nobody really wants to claim you sort of speak. And so that’s where that six-hour rule comes in, and I guess that’s how they decide, you know. So, if you’re within six hours of a US port, then it’s covered. And if not, then I suppose you better have some travel insurance, because otherwise it could be very costly. So, I do recommend on cruises to get travel insurance.

 

Steve Sedahl  14:58

Let’s, let’s talk. Medigap, uh, plans?

 

Lisa Lauro  15:01

Yeah, Medigap plans, C, D, which, C is no longer available, so D, G, M and N, which the two most popular ones, because of the coverage is the most comprehensive are G and N, but those provide limited foreign emergency coverage, so G and N specifically cover 80% of foreign travel, up to a maximum lifetime benefit of $50,000 and so in these specific scenarios, you know that I like to think of it as like, they just like to get you stabilized and get you home so that you can get the rest of your care here, and, in the States. But, but, but they, you know, again, Original Medicare A and B doesn’t cover foreign travel, but the Medigap G and N will at least give you some foreign emergency coverage.

 

Steve Sedahl  15:52

Good, good to know.

 

Lisa Lauro  15:52

And then last one is Advantage plans. They offer limited international coverage. So if you are, have an Advantage plan and you’re traveling internationally, they are contracted to deal with emergency situations in terms of an urgent care or an ER, but so if it’s not like if you’re sick, but it’s not an emergency, I would probably go to the urgent care over the ER, sure, because they may say this, this wasn’t an emergency, you know what I mean. So just you know, be mindful of that as well.

 

Steve Sedahl  16:21

All right. Well, good to know. So, because of, vacation season is here, let’s keep that in mind. Does, I like this? We talk about alternative therapies. We talked about this before, but let’s break it down. So, what does it cover? What doesn’t it cover? Acupuncture, chiropractic, any other alternative medicines or treatments?

 

Lisa Lauro  16:40

Sure, sure. Acupuncture. So, Medicare covers up to 20 visits per year.

 

Steve Sedahl  16:45

So really, that’s it. That’s all legit, yeah.

 

Lisa Lauro  16:49

Yeah, I mean, honestly, acupuncture is one of those things I’d like to try. It’s like, right? Like to try it for once, just to see, because I’ve never done it, but I also don’t know anybody who’s done acupuncture. I would love to speak to someone who has just to kind of see what their experience was, but it’s nice to know, I mean, that’s something that maybe some people have considered, but didn’t think it was covered. And so, in this particular case, you can go, if you’re on Medicare, 20 visits per year for chronic lower back pain. So, it is specific: chronic, chronic lower back pain. That also brings us to the chiropractor, which Medicare covers spinal manipulation for subluxations, but not routine adjustments or X rays. So very specific there, sure, and then… go ahead

 

Steve Sedahl  17:34

So… spinal manipulation. I mean, that, so are you then injured? Does that? Does that the qualifier, ‘cause you said not just, that’s not, uh, routine adjustments.

 

Lisa Lauro  17:46

So subluxations are your adjustments. So I think, right, like to fix a subluxation is a misalignment of your spine, and from what I understand. So, so I think, yeah, like, I guess if you are injured, because how do they differentiate between routine? I see your question, yeah, routine, but not routine adjustments. I don’t know. I guess if it is an injury, I would imagine that would be where the difference is.

 

Steve Sedahl  18:13

Fair enough. Anything, other alternative therapies covered?

 

Lisa Lauro  18:17

Treatments like massage therapy, naturopathy and homeopathy, any type of holistic type stuff, they are not covered.

 

Steve Sedahl  18:26

Okay. And, all right, so, but it does cover acupuncture and chiropractic, I mean, that’s, that’s pretty good, yeah, I mean, because, I mean, there’s, there’s some insurance, you know, that doesn’t cover that. Right? Just regular..

 

Lisa Lauro  18:40

Right, right. And some Advantage plans. So like medi, you know, Medicare, when we talk about Medicare, we’re being really broad, because are we saying, Are we talking A and B, we talking Medigap, or are we talking Advantage right? And so, you know, the there are in our local market, here in Pittsburgh, there are some Advantage plans that have acupuncture, not many, but the majority of them do cover some type of chiropractic. Again, with those Advantage plans, it’s going to be whether the doctor is in network or not. Okay?

 

Steve Sedahl  19:12

All right. Fair enough. So let’s see, talking about delaying Medicare. So, in other words, if you’re still working, or you know you’re working and, or maybe you’re not working, but you’re covered by your spouse’s insurance. Let’s set up that scenario. So how, can I delay?

 

Lisa Lauro  19:26

So, you can well, so, let’s say if you are, if you’re on your spouse’s insurance, yes, you can delay, as long as it’s considered credible coverage. Okay, but if you are not on your spouse’s insurance, you cannot just opt for a COBRA, because COBRA is not considered credible coverage

 

Steve Sedahl  19:49

Wow, did not know.

 

Lisa Lauro  19:52

I know which it which, to me, is a little weird, because, like, if you have credible group coverage, and then your COBRA is just an. Extension of that. Why is that not considered, so a lot of people don’t realize that. You know, folks that are under 65 can bridge the gap with COBRA until they turn 65 and get on to Medicare. But once you hit 65 then you kind of need to enroll into Medicare Part B, because otherwise you are going to get a penalty, since Medicare doesn’t deem COBRA as credible coverage. Okay? It is weird. Yeah.

 

Steve Sedahl  20:31

Yeah, that’s weird. All right, it’s good to know. Folks, if you want to get in, 724-293-6653, so what’s TRICARE for life? I don’t even know what that is.

 

Lisa Lauro  20:39

TRICARE for life is for veterans. Oh, okay, they’re veterans that are retired. I believe it’s the retirement program for veterans.

 

Speaker 3  20:49

Oh, all right, sure, sure, I got a friend that’s involved in that. Yeah.

 

Lisa Lauro  20:53

Yeah, I’m not 100%, now. I’m having a little bit of brain fog this morning, but this requires an enrollment into Medicare A and B. So yeah, in order to have TRICARE for life, you have to have A and B, because the reason why is Medicare is the primary payer, and then TRICARE pays after so, so that is important that you would sign up for A and B, because TRICARE is secondary.

 

Steve Sedahl  21:16

Okay, and that’s why we’re talking veterans of VA benefits. How does that fit into Medicare? Or…

 

Lisa Lauro  21:22

You can, yeah, you can have both VA and Medicare, but VA benefits only cover you at the VA facilities. So, if you wanted to go to a civilian doctor, you’re going to want to, you can pair your VA benefits with an Advantage plan, and they have specific Advantage plans for veterans, which are really nice. They’re super, super nice plans that they’ve put together, especially here in PA with a lot of you know, sometimes veterans, they don’t have dental or vision coverage, and so they can get the what’s called an MA-only. It’s a Medicare Advantage plan that doesn’t have prescription drug plan in it, because the veterans go to the VA for their prescription drugs and, but what, what’s nice for this is that usually they’re very the plans premiums are pretty inexpensive. Sometimes they’re zero premium. They will have benefits for dental, benefits for vision, the over the counter allowance, which is going to give you some money. Most plans are quarterly, where you can use that money towards things that you would get at a pharmacy, and not your prescriptions, but things like, that you would think of on the shelves of a pharmacy. So, your pain relievers, allergies, stomach, vitamins, medicine, stomach medicines, things like that. So, so the VA benefits you’re you, it would be nice to pair that, so you have your A and your B, and you have your VA, and then you compare that with an Advantage plan. So, if you don’t have that now, the annual enrollment period up in, coming up in October 15, you can pick up an Advantage plan and reap the benefits of some of those extra things I mentioned.

 

Steve Sedahl  23:13

Sure, from a veteran standpoint, I mean that, there’s really a lot to consider, and I know that you’ve got a lot of veterans in that war… in your world. So, yeah, it’s important, yeah, all right, so let’s see we got one more quick one. Can I get Medicare if I never worked?

 

Lisa Lauro  23:28

You can. You can. The only difference is that you would have a premium, most likely for Part A, if you or your spouse work 10 plus years, then Part A is free. You can claim spousal benefits. To do that, you have to go down in person to the Social Security office and bring a marriage certificate with you. You can’t apply for spousal benefits online. Now, if you or your spouse worked less than 10 years, you must buy Part A and it could be anywhere from if it’s less than 30 to 39 quarters that you worked, then the premium for that part A would be $285 and if it’s less than 30 quarters of work in your lifetime, then you could pay upwards of $505 a month for your part A. So, it’s eligible to you, but you would have to buy it.

 

Steve Sedahl  24:21

All right, fair enough. Well, on that note, we’re going to call it a show, 724-293-6653, is the number. Do give us a call. We are going to say so long for this week. Lisa, we’ll come back next week and do it again.

 

Lisa Lauro  24:32

That sounds great. Thanks, Steve.

 

Speaker 4  24:40

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Outro  26:39

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