Cash Flow Is King
We don’t live off lump sums, after all, but rather we live off the income they generate. In retirement, you will have substantial monthly income that is unattached to any lump sum. That’s Social Security and perhaps a pension.
Let’s take it one month at a time.
We’ll start with Medicare, since with a few exceptions such as federal retirees, that’s where most of us will end up.
In 2023, the standard Medicare premium for Part B is $164.90 per person. If you’re collecting Social Security, it’ll come directly from your check. Chances are, you’ll barely notice the dough is gone, just as most people can’t quote their pre-tax employer-deducted health care premium. Seven in 10 enrollees pay just the standard premium.
The tab can be higher for retirees that Uncle Sam considers high-income. Make more than $97,000 (double if you’re married), and you’ll find yourself in IRMAA land. This stands for Income-Related Monthly Adjustment Amount. Make enough and your Part B premiums more than triple to $560.50 a month. Only three in 10 enrollees pay an additional premium for Part B.
We spend a lot of time managing this for our clients. It’s no fun and makes people mad. But, by definition, the folks it affects can afford it. This unwelcome hit won’t cause them to be evicted because they can’t make rent.
Is the Medicare Part B premium an out-of-pocket expense, like that cable bill that keeps creeping up? Technically, I say yes and model it as such for my clients. Practically, it feels automatic, provided you are collecting Social Security. (If not, the bill comes quarterly so you’ll feel the pain.)
Medicare Part A, which covers hospital stays, is free to collect, provided you’ve paid into the system or are married to someone who has. You may pay for this, but it’ll be indirectly and because you’re working and paying FICA while collecting it.
Alas, there are at least two more potential bills. I say potential because just as high-income people pay more for Medicare, low-income retirees may actually pay nothing.
Filling[EP1] [GU2] [GU3] the Gaps
Medicare arrived on the scene in 1965. Parts A and B reflected the structure of private health insurance in those days. Things have changed a lot since then, but less so with traditional Medicare. This traditional Medicare structure creates plenty of deductible and coverage gaps that should be filled.
Part A picks up the tab for hospital stays only after a $1,600 deductible which covers the patient’s share of costs for 60 days. For days 61 to 90, the daily bill jumps to $400. For days 91 to 150 it’s $800 per day and unlimited after that. There’s no out-of-pocket maximum.
Part B pays the doctors. The deductible is a more manageable $226 after which patients face a 20% co-pay.
Clearly, the costs could stack up for a long hospital stay or an expensive chronic condition. So, you’ll likely want to get supplemental or Medigap insurance, enroll in a Medicare Advantage plan, or pick up some government subsidy if eligible.
The average cost for the most popular Medigap plans is between $135 and $185 a month. Medigap is extra insurance you can buy from a private health insurance company to help pay your share of out-of-pocket costs in Original Medicare.
One in two Medicare recipients are enrolled in Medicare Advantage plans. The average monthly premium for these plans in 2022 was $18.
As of 2022, there are 12 million people age 65 and older who are dually eligible for Medicaid and Medicare. This means that they are enrolled in both programs and receive benefits from both. Dually eligible individuals make up more than 15% of all Medicaid enrollees.
Suffice to say that many people don’t face the same health care costs in retirement as those who are enrolled only in original Medicare.
But we’re working on the worst case, so let’s stay with paying for a gap plan.
So now we are up to $350 per month per person ($164.90 for Medicare Part B and $185 for a Medigap plan) or $700 per month per couple.
Don’t Forget Your Pills
There’s also Part D, the prescription drug plan, to consider. The average monthly cost of these plans in 2023, according to KFF, is $43 per month.
Add it Up
For the middle-income American retiree, the bill per beneficiary will[EP4] [LM(5] be just under $400 a month. Of this, $228 will come out of pocket. In fact, according to the Consumer Expenditure Survey, the average household headed by a 65-year-old will spend $4,954 on health insurance premiums. Given that the average income is $63,319, this is 8% of income.
In our practice, we conservatively estimated $1,000 a month or $12,000 per year per Medicare-eligible couple when doing projections.
Beware of Averages
No doubt, the average won’t apply to you. If you’re reading Retirement Daily, chances are you have a few dollars. If too many of these dollars are in the form of monthly income you will confront IRMAA. This won’t put a smile on your face. But it won’t send you to the soup kitchen either. We employ many strategies to contain this beast for our clients, but that’s not the focus of this article. It’s not a scarcity of funds problem. (Read Avoid This Pitfall When Planning for IRMAA.)
For those under the IRMAA limits, you may have some great options to future reduce your costs. Start with your employer. KFF finds that one in five Medicare beneficiaries are getting some employer support. The help may come in three potential forms.
First, many large employers help pay for the supplemental plans. Take that away, and you’re down to $208 per person with only Part D coming from your checking account.
A second piece of help may be an employer-funded Health Reimbursement Account (HRA). This may come as an annual subsidy to use for health care or as a one-time lump sum at retirement of which you can spend a portion each year.
Finally, during your working years, your employer may have put plenty of money into a health savings account (HSA) for you. This travels with you. For some reason, it cannot be used to pay for Medicare supplemental plan premiums. It can, however, be used to reimburse you for Medicare Part B premiums as well as other qualified health care expenses.
The Zero-Cost Option
How would you like to pay nothing?
Your answer is probably dependent on why? Recall that the KFF study shows that two in 10 Medicare recipients are on Medicaid as well. This is known as dually eligible and if one qualifies, the price of Medicare and gap insurance is zero.
In many states, it’s rolled up into the Medicare Savings Programs and there are several plans. The federal government has an income limit as low as $20,000 and an asset test of $13,630 for married couples. At this level of income and assets, any premium would be a huge hardship. This plan takes care of the neediest American seniors.
That said, I’ve known people with high six figures in investment assets who get free Medicare. Crazy, perhaps, but nevertheless true. They’ve just figured out how to work the system.
It’s very important to understand the rules and how they are applied in the jurisdiction in which you live. Although the federal website lists asset tests, they may be different in your state. In Connecticut, people with incomes below $28,680 pay nothing for a comprehensive Medicare package.
Income is not what you spend. It’s what you remove from taxable accounts and other taxable sources, such as Social Security and pensions. Retire at 65 and delay your Social Security until age 70. Limit pre-tax withdrawals to $2,300 a month and you’re good to go. Remove the rest from a bank account. Take low-cost loans from your life insurance policy. Or maybe from a reverse mortgage. This is not considered income. These are just some options. There are plenty more.
What about your assets? The government of Connecticut is clear. “Is there an asset limit?” the brochure asks. “No. There is no asset limit for any of these programs.”
Crack Your State’s Code
Check your state’s rules and plan accordingly. What works in Connecticut won’t work in my new state of Florida.
These savings can surely add up. They’ll be time limited, however. At age 70, you’ll be smart to collect Social Security and that will put you back on a payment plan.
Be careful, because you may give all the savings back when your RMDs kick in at age 73 if that puts you into IRMAA. This stuff is tricky. You must do the calculations. The key that makes this strategy possible is having the foresight to build up after-tax assets that can be drawn down prior to age 70.
For You Young’ns.
You can see that Medicare is not going to break you. Back to the summary. If you’re in IRMAA, you can afford it. If you’re under-resourced, you have the Medicare Savings Programs, which are are federally funded programs administered by each individual state. These programs are for people with limited income and resources to help pay some or all of their Medicare premiums, deductibles, copayments, and coinsurance.
If you’re in the middle, you have many options including zero-cost Medicare Advantage, and perhaps Medicare Savings with enough planning.
But what about getting to Medicare for early retirees? Leaving employer-supported group health plans is plenty scary.
If this applies to you, take a deep breath. It’s far better than you think. The old days of job-lock are gone, having given way to fun-and-games with the Affordable Care Act (ACA).
Keep (Him/Her) Working
The best option for those who have this option is to stay on a spouse’s plan—that is, keep a spouse working while you, well, take it easy. I’ve seen this work well, at least for the lounger. If you’re not married, see if you can get into a committed relationship quickly and claim domestic partnership with a still productive member of society. Given the employer subsidy, group insurance is usually a better deal than the stuff we get on the individual market.
If you’re technically single like me or lucky enough to be retiring in synchrony with a spouse—and you’re not age 65—you have some good options.
There’s always 18 months of COBRA, a thankfully cogent acronym for the Consolidated Omnibus Budget Reconciliation Act. This law allows you to keep your group plan for 18 months provided you pay 102% of the premium. Retire close to age 65 or have serious health issues and this can be an attractive option. Others will likely head to the ACA exchanges.
Your Time to Collect
Every American now has a right to health care provided through an exchange at standardized prices. These exchanges are either state-run or facilitated by the federal government through healthcare.gov. This is how I get my insurance so I’m very familiar with it and I know it works and works well.
Prior to age 65, you’ll have an array of insurance options. You can get PPOs, HMOs, and EPOs. You can get high-deductible health plans with HSAs, my favorite. You can’t get turned down or charged more due to your health, except for smoking.
The quoted premiums may in fact be quite large. Don’t worry. You’ll likely find a workaround.
Uncle Sam to the Rescue
The premiums in most cases are too much for people of modest income to afford. We’re a democratic republic and this is understandably unacceptable to the people who want our votes. Therefore, subsidies (advance premium tax credit) are available for those of limited income.
By now, you likely can guess the strategy. Uncle Sam’s generous subsidies are based on taxable income. That is, income produced by earnings, withdrawals from pretax retirement accounts, and dividends and interest. The stuff that hits your tax return.
Just as post-65-year-olds can get free Medicare by drawing down bank cash instead of tapping taxable IRAs, the pre-65 set can draw down gobs of government money to pay their insurance premiums. Your $2 million in IRAs, 401(k)s, Roth IRAs, non-qualified annuities, and low-interest bank-accounts have no effect on the subsidies. Only the taxable income created by these accounts dings you.
Free Ride Until 70
If you prepare early enough and apply some street smarts, you may be able to retire early and get a decade of free health care. Pile up your funds in places that don’t count: after-tax investment accounts, bank accounts, cash value life insurance, non-qualified annuities, and Roth IRAs.
So much for needing that $315,000 that Fidelity claims you need. Use it on boats, vacations, cars, and dining out. If you’re particularly frugal, you might calculate and invest the subsidies you pulled down from the ACA and Medicare Savings Program. You can then use the government’s money and the earnings on it to fund a lifetime of future Medicare premiums. You may make money on the deal.
Back here in reality
Now for the disclaimer. I don’t know you. Perhaps none of these strategies apply to you. You may need to fret about health care costs in retirement. If you find yourself on Medicare Parts A, B, and D with no access to a Medicare Advantage plan or a reasonably priced Medigap plan, you may be in big trouble.
I doubt that this is the case. My guess is that once you hit Medicare, you’ll be well covered. At an average combined monthly cost of $2,069, your utility, grocery, and housing bills—all necessities—will be a far larger burden than health care. Using Fidelity’s methodology, you’ll need $500,000 in savings just for these. Don’t hold your breath waiting for a study and news story on this. It violates common sense. It’s easily covered from the $2,739 a month your household receives in Social Security. Who would publish that drivel.
Michael Lynch CFP is a financial planner with the Barnum Financial Group in Ft Myers, FL, where he focuses on his clients’ finances so they can focus on their lives. He teaches consumer-oriented financial planning courses for leading organizations, including Madison Square Garden and Yale New Haven Health Systems. He is a member of Ed Slott’s Elite IRA Advisor Group and the author of Keep It Simple, Make It Big: Money Management for a Meaningful Life, October 2020, and It’s All About the Income: A Simple System For a Big Retirement, May 2022. You can find more articles and videos at www.simpleandbig.com. He can be reached at mlynch@barnumfg.com or 203-513-6032.
Michael Lynch is a registered representative of and offers securities and investment advisory services through MML Investors Services, LLC. Member SIPC. [link to www.SIPC.org on electronic advertisements] [6 Corporate Drive, Shelton, CT 06484 Tel: 203-513-6000
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