Have Job-Based Health Coverage at 65? You May Still Want To Sign Up for Medicare

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Michelle Andrews

When Alyne Diamond fell from a horse in August 2023 and broke it, her employer -based health plan via Unitedhealthcare covered her emergency care in Aspen, Colorado. He also covered pain management and related physiotherapy after his home in New York. Invoices have totaled more than $ 100,000.

The real estate lawyer, now 67, was eligible for Medicare at the time but had not registered. As she was still working, she thought that her employer’s health insurance plan would cover her.

This misunderstanding has had financial repercussions with which it continues to face today.

More than a year after his driving accident, Diamond was back in the emergency room after tripping at a stage when entering a New York restaurant. His face covered with blood, Diamond was examined by the staff, who made several computed tomography. The bill for this care: $ 12,000.

This time, however, insurance coverage was not a routine. Almost all of his statements have been refused.

Diamond was caught in a fairly common coverage clip: people who have group health insurance when they become eligible for Medicare are sometimes on the hook for their medical bills because their group plan ceases to pay.

Diamond contacted several people in Unitedhealthcare before discovering why the insurer refused to pay his complaints.

When Diamond was 65 years old in 2022, Medicare – without his knowledge – became the “main payer” of his complaints, which means that the federal health program for the elderly or disabled was supposed to take the lead to cover his medical invoices, before other insurers paid anything. (As a secondary payer, Diamond’s employer policy has recovered 20% of what Medicare would have paid.)

If she had signed up for the government insurance plan when she was 65 years old, Diamond could have avoided a financially perilous situation which left her unexpectedly to the medical expenses she incurred during this period.

She started understanding what had happened when she did investigations to the allegations refused.

Diamond said he was told that Unitedhealthcare had audited his complaints last year and determined that he had misunderstood his care, perhaps because his expensive medical allegations after his fall of the horse raised a red flag.

The insurer not only ceased to pay the current complaints, but also moved to Claw back from the tens of thousands of dollars which he had paid for providers for two years since she had 65 years. Some of these suppliers are now looking for a payment.

“It’s horrible,” she said. “For about two months, I was devastated. I said to myself, “Where will I get the money to pay all these people?” There is my retirement. »»

The error has already cost her $ 25,000 and could cost her much more if the providers continue to invoice her for amounts that United Healthcare recovered for the care she received before registering in Medicare in February.

A spokesperson from Unitedhealthcare refused to provide a record on the record, quoting security problems.

Patient defenders say they frequently hear people who, like Diamond, thought they didn’t need to register for Medicare at the age of 65 because they had group health coverage.

This hypothesis is generally correct if they or their spouse works in a company with at least 20 employees. In this case, the employer’s coverage is considered primary and can delay registration in Medicare as long as their spouse or spouse continues to be employed.

But if someone has a coverage of the employer through a company with less than 20 workers, Medicare generally becomes the main payer when he is 65 years old. The property law firm in which Diamond is a partner has a handful of employees.

Similarly, if someone is over 65 and has a coverage for the health of retirees or has left their job and has chosen to continue its employer coverage under the Consolidated Omnibus Budget Act, also known as Cobra, Medicare pays first. The problem can also arise for people under the age of 65 if they are eligible for Medicare due to a handicap. In these cases, Medicare pays first if they or their family member works in a company with less than 100 employees.

If the people of these groups do not register for Medicare when they become eligible, they can find themselves responsible for all their medical invoices for years. (They may also have a penalty for late registration on the Medicare program.)

“It is very alarming and there is no current solution to the situation,” said Fred Riccardi, president of the Medicare Rights Center, based in New York, a national patient for defense of patients.

The Centers for Medicare & Medicaid Services did not respond to a request for comments.

Mark Scherzer, a German lawyer, New York, who helps people with insurance problems and who advised Diamond, said he was receiving calls sometimes a month with people who face this problem.

“What I see constantly now is that insurers go up and they retreat the doctor’s money and then go up the patient’s money,” he said.

Expected complaints can trigger an insurer to examine someone’s coverage.

These major complaints “seem to be on the insurer’s radar,” said Casey Schwarz, principal lawyer for federal education and federal policy at the Medicare Rights Center.

United Healthcare recovered more than $ 50,000 in medical invoices from some of the suppliers who treated Diamond in New York after his driving accident. She has paid them about $ 25,000 so far. Some agreed to let him pay the amount that Medicare would have paid.

But there may be more invoices to come. Under the New York law, health plans are two years after complaints are paid to recover providers’ payments, and providers are three years to continue patients for medical debt. Thus, while it is still time for the diamond to be billed, the clock will eventually run out.

Diamond plans to continue the broker who manages the health plan for his business and other advantages for negligence.

“The rules of secondary payment of health insurance essentially say that if you have not registered because you did not know that Medicare was supposed to be primary, it is on you,” said Melanie Lambert, main medicare defender at the Center for Medicare Advocacy in Connecticut.

Lambert said she had seen the problem “several times”. In some cases, if a beneficiary may demonstrate that they have been misled by an employer or a federal employee, it may be eligible for help or a special registration period, she said.

In a letter of 2023 to the acting secretary of the Ministry of Labor, the National Association of Insurance Commissioners recommended applying a “common sense rule to Cobra levels, individual health insurance and other sources of coverage: those who are entitled to part B Medicare but which do not register should not lose services that they pay from a source of non -medical coverage”.

The Ministry of Labor did not respond to a request for comments.

Previously, people began to collect social security services, then automatically obtained maladie insurance at the age of 65.

Now registering in Medicare is more complicated for many people, said Tricia Neuman, principal vice-president and executive director of the Medicare policy at KFF, a non-profit organization of health that includes Kff Health News.

“While more and more people delay social security and delay the pursuit of health insurance, there are more opportunities for people to make mistakes, and these errors are expensive,” said Neuman.

Coverage experts claim that there is no clear requirement for insurers, employers or the federal government to inform people of how payment rules governing the coordination of benefits between health plans can change when they become eligible for medication.

Information appears in a table of the government’s “Medicare & You” manual, if someone knows how to look for it. But it’s not easy to find.

A simple solution could solve many of the problems that people face in this area, said Scherzer. Given that each health plan knows the age of their registrants, why not force them to inform people approaching 65 of the possible problems of coordination of advantages with health insurance? “It’s so simple and obvious.”

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