Affordable Care Asks

Affordable Care Asks: Medicare Rights

You won’t be told this, but when you become Medicare eligible, you will lose your ACA Marketplace Subsidies.

There is no way to opt out of Medicare Part A without losing SSI benefits.

This needs to change.

Hall v. Sebelius

A group of 0ver 65 Medicare eligible retirees requested to opt out of Medicare Part A because they preferred their existing private coverage. The 2012 response to their request is the situation I now find myself in, that anyone who declines Medicare benefits will also lose Social Security benefits. Hall felt the linking of Social Security and Medicare as being beyond the SSA’s statutory authority. Hall lost. I am wondering if my case and the birth of the Affordable Care Act is reason enough to reinvestigate this loss and retry. This feels unjust. Read the Hall decision here.

My Story:

  • I have until December 7th, 2015 to Opt out of Medicare Part A.
  • My Medicare Part A benefits were not my choice and prevent me from receiving my Marketplace subsidies.
  • An ‘opt out’ does not exist without a loss in income.
  • Therefore I will lose my SSD benefits if I opt out of Medicare Part A.

Since losing my Health Republic insurance, I have worked endlessly to keep my medical team in tact. Amazingly, there is a Marketplace plan that will allow me to do this. But since I am no longer eligible for ACA subsidies, I can’t afford that plan. Medicare does not offer me the continuity of care I so require.

If I don’t sign up for Medicare Part B by December 7th, I will be charged a penalty every month for the rest of my life.

This fight isn’t just for me, there are a lot of people in my position and we need some legislative changes.

Barry’s Story:

My friend Barry recently reached out. Barry has CIDP. In reading this, you will notice two things. First, Barry is a tried and true Texas Republican (I am neither a Texan or a Republican). Second, the desire to opt out of Medicare Part A crosses partisan lines. So what’s the hold up?

I share your frustration. I’m facing similar problems. Since I’ve been granted SSDI (which I was contractually required to apply for under my contract with my private disability insurer), I’m required to enroll in Medicare. Never mind that I don’t want Medicare because it provides worse coverage of my IVIG therapy (at a greater cost to me, out of pocket) than I could get from a private insurer. It amazes me that the government forces me to accept its “benefit,” even when I’d be much better off (as would the taxpayers) without it.
Meanwhile, since it’s illegal for me to buy group health insurance through the Texas bar, I also can’t insure my wife and kids that way. So they’re stuck with the ACA exchange policies, none of which is accepted by their doctors. So now we’re scrambling to find a new pediatrician and a new endocrinologist for my son, who’s a type 1 diabetic and sees his doctor very frequently. If we can’t manage that by January — and we’ve been trying for over a month, now — our only option will be to take him to the ER for his routine diabetes care, which happens, on average, twice a month. He’ll miss a full day of school, my wife will miss a day of work, and the cost will be many times what it would be under a rational system.
It’s hard to argue that the pre-Obamacare system made much sense, but it’s also hard to argue this is much better. At least the old system didn’t come with a trillion dollar price tag.
Note, BTW, that I’ve been practicing law for 11 years and I nonetheless find the Medicare rules as opaque as if they were written in ancient Sumerian. How an average senior can be expected to navigate them is beyond me.

Federal Asks

  • Medicare Part A can no longer be considered the ‘Minimum Essential Coverage’ for Medicare recipients (aka those most in need) unless the recipient specifically asks for it. One must either be able to opt out of Medicare Part A, or Part A must work in conjunction with Marketplace subsidies. Part A is not enough for elderly and disabled people. And forcing young disabled SSD recipients onto Medicare disincentives and creates further hurdles in getting off of disability (which is a goal of mine).
  • There was no trigger in place to notify Marketplace providers when insurees became Medicare eligible until 2016. Anyone who unknowingly received both Medicare Part A alongside Marketplace subsidies will be double taxed. This needs to be rectified.
  • Many of the top hospitals in New York aren’t covered by Marketplace plans. This is because of the exorbitant rates they charge. I understand the need for insurance companies to drive down medical costs, but there needs to be a system in place that ensures every local hospital system is covered by at least one Marketplace plan for those most in need of proximity or specialty. There are no Marketplace plans covering Memorial Sloane Kettering in NYC. MSK is the best cancer hospital in the world and is now unattainable for NY residents on the Marketplace.

State Asks

  • Patients need to be given greater resources to advocate for their needs.
  • There needs to be a system in place where Marketplace users can report coverage issues, flaws and oversights.
  • If an insuree is forced off of a Marketplace plan or if a provider is dropped, there must be an application system in place for chronically ill patients to apply for out of network continuity of care coverage.
  • Continuity of Care must be a priority in Mental Health treatments. Please consider this Timothy’s Law 2.0.


11/7/15: New York state is stepping in. The official November 15th deadline has been moved back to November 30th. There will be an application hotline for those applying after the 15th. There will be steps put in place that allow Health Republic consumers to continue coverage at New York Presbyterian and Memorial Sloane Kettering for up to a year, since no other marketplace plan covers NYP or MSK.

But it still doesn’t resolve the Medicare issues that came to light through this ordeal. I am still virtually uninsurable as of 2016 and will have to ‘trick the system’ to maintain coverage for the month of December.

Lastly, Thanks New York Times for helping me tell my story.

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