TIME Health Care

Clinic Loses Accreditation After Joan Rivers’ Death

Joan Rivers-Death Investigation
Tina Fineberg—AP Yorkville Endoscopy seen in New York, Sept. 5, 2014.

The clinic has been cited for multiple errors in its care of the late comedian

The New York clinic where TV personality Joan Rivers underwent vocal cord surgery, before her sudden deterioration and death, will lose its federal accreditation at the end of the month.

As of Jan. 31, Yorkville Endoscopy will no longer receive Federal funds for services given to Medicare and Medicaid beneficiaries, the Huffington Post reports.

Earlier this past year, the New York State Department of Health determined that the clinic made multiple errors during Rivers’ care. Rivers died on Sept. 4 after suffering brain damage from lack of oxygen after she quit breathing during surgery only a few days earlier.

An employee of the clinic also reportedly took a photo of Rivers during the surgery.

The clinic released a statement, saying: “We are continuing to work with all regulatory bodies. We intend to communicate with CMS and appropriate authorities to have the decision reversed. Yorkville continues to be a licensed facility and perform procedures while cooperating with the regulatory process.”

MONEY Health Care

Why You Could Have to Foot the Full Bill for a Weight-Loss Drug

The government has approved more drugs that suppress your appetite, but not all insurers will pick up the tab for the prescription.

In December, the Food and Drug Administration approved a new anti-obesity drug, Saxenda, the fourth prescription drug the agency has given the green light to fight obesity since 2012. But even though two-thirds of adults are overweight or obese—and many may need help sticking to New Year’s weight-loss resolutions—there’s a good chance their insurer won’t cover Saxenda or other anti-obesity drugs.

The health benefits of using anti-obesity drugs to lose weight—improvements in blood sugar and risk factors for heart disease, among other things—may not be immediately apparent. “For things that are preventive in the long term, it makes plan sponsors think about their strategy,” says Dr. Steve Miller, the chief medical officer at Express Scripts, which manages the prescription drug benefits for thousands of companies. Companies with high turnover, for example, are less likely to cover the drugs, he says.

“Most health plans will cover things that have an immediate impact in that plan year,” Miller says.

Miller estimates that about a third of companies don’t cover anti-obesity drugs at all, a third cover all FDA-approved weight-loss drugs, and a third cover approved drugs, but with restrictions to limit their use. The Medicare prescription drug program specifically excludes coverage of anti-obesity drugs.

Part of the reluctance by Medicare and private insurers to cover weight-loss drugs stems from serious safety problems with diet drugs in the past, including the withdrawal in 1997 of fenfluramine, part of the fen-phen diet drug combination that was found to damage heart valves.

Back then, weight-loss drugs were often dismissed as cosmetic treatments. But as the link between obesity and increased risk for type 2 diabetes, heart disease, cancer and other serious medical problems has become clearer, prescription drugs are seen as having a role to play in addressing the obesity epidemic. Obesity accounts for 21% of annual medical costs in the United States, or $190 billion, according to a 2012 study published in the Journal of Health Economics.

The new approved drugs—Belviq, Qsymia, Contrave and Saxenda—work by suppressing appetite, among other things. Saxenda is a subcutaneous injection, the other three drugs are in pill form. They’re generally safer and have fewer side effects than older drugs. In conjunction with diet and exercise, people typically lose between 5% and 10% of their body weight, research shows, modest weight loss but sufficient to meaningfully improve health.

The drugs are generally recommended for people with a body mass index of 30 or higher, the threshold for obesity. They may also be appropriate for overweight people with BMIs in the high 20s if they have heart disease, diabetes or other conditions.

In 2013, the American Medical Association officially recognized obesity as a disease.

Nevertheless, “people still assume that obesity is simply a matter of bad choices,” says Ted Kyle, advocacy adviser for the Obesity Society, a research and education organization. “At least half of the risk of obesity is inherited,” he says.

Many people who take an anti-obesity drug will remain on it for the rest of their lives. That gives insurers pause, says Miller.

The potential cost to insurers could be enormous, he says.

Susan Pisano, a spokesperson for America’s Health Insurance Plans, a trade group, says the variability of insurer coverage of anti-obesity drugs “relates to issues of evidence of effectiveness and evidence of safety.”

In 2012, the U.S Preventive Services Task Force, a non-partisan group of medical experts who make recommendations about preventive care, declined to recommend prescription drugs for weight loss, noting a lack of long-term safety data, among other things. But its analysis was based on the older drugs orlistat, which is sold over the counter as Alli or in prescription form as Xenical, and metformin, a diabetes drug that has not been approved for weight loss but is sometimes prescribed for that by doctors.

The task force did recommend obesity screening for all adults and children over age 6, however, and recommended patients be referred to intensive diet and behavioral modification interventions.

Under the health law, nearly all health plans must cover preventive care recommended by the task force without cost sharing by patients. Implementation of the obesity screening and counseling recommendations remains a work in progress, say experts.

Dr. Caroline Apovian, director of the Nutrition and Weight Management Research Center at Boston University, says many of the patients she treats can’t afford to pay up to $200 a month out of pocket for anti-obesity drugs.

“Coverage has to happen in order for the obesity problem to be taken care of,” says Apovian. “Insurance companies need to realize it’s not a matter of willpower, it’s a disease.”

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

MONEY Medicare

The Huge Health Care Expense Medicare Won’t Pay

BurwellPhotography.com—iStock

For peace of mind, you need more than Medicare.

Medicare helps more than 55 million Americans with their health care expenses, with most people age 65 or older qualifying for coverage. With benefits for everything from hospital stays to doctors’ visits, Medicare is an essential part of retirement financial planning for older Americans in dealing with one of the largest expenses they bear. Yet there’s a huge gap in Medicare coverage that doesn’t provide financial assistance for services that an estimated 70% of senior citizens will need at some point during their lives. In order to prepare yourself for those expenses, you’ll need to make separate provisions outside Medicare to ensure that you’ll have the financial resources necessary to cover the costs of care.

Nursing homes, long-term care, and the Medicare gap

Medicare covers many things, but the coverage it provides for nursing homes and other types of long-term care are extremely limited. Medicare Part A, which covers most inpatient care such as hospital visits, does make a provision for covering the costs of a skilled nursing facility. If you qualify, Medicare will pay 100% of the cost of skilled nursing facility for 20 days, and it will cover all but a $157.50 per day copayment in 2015 for the next 80 days of approved care at such a facility.

However, in order to qualify for those services, you need to have had a qualifying hospital stay of at least three days, and the care you receive at the facility must be connected to the treatment you were getting in your initial hospital visit. Once your 100 days is up, you’re responsible for all costs — and you’ll need a break of at least 60 days in a row in order to end your current benefit period and renew your benefits for future coverage.

More importantly, many people in nursing homes aren’t receiving skilled nursing services and therefore don’t qualify for Medicare benefits at all. If the only kind of care you need is custodial care such as helping you get in and out of bed, bathing, or getting dressed, then Medicare won’t cover those costs.

When it comes to home health services, Medicare also has limits. You’re entitled to up to 100 home health visits under Medicare Part A following a hospital stay, and Part B also provides certain home health benefits. But to qualify, your doctor has to certify that you’re homebound, and you must need skilled nursing care or certain other treatment such as physical therapy, speech-language pathology, or occupational therapy services. Again, Medicare won’t cover purely personal care, making seniors responsible for much of their own costs for getting in-home help.

How to bridge the gap

Unfortunately, the costs that Medicare doesn’t cover play a part in most retirees’ lives at some point during their retirement. According to a study from the Department of Health and Human Services, almost seven out of every 10 Americans turning age 65 will need long-term care at some point in their lives.

Most traditional insurance, including medical and disability insurance, follow Medicare’s rules in limiting coverage to those whom are medically necessary and involved skilled, short-term care. Even supplemental Medicare policies typically only cover the $157.50 copayment for covered services and provide nothing for long-term care.

In order to get insurance coverage for long-term care needs, you’ll need a specific long-term care insurance policy. These specialized policies cover a wide array of services, ranging from assisted living facilities and nursing homes to home-healthcare and personal care needs. Premiums depend on the age at which you buy insurance, the maximum daily coverage you choose, and the lifetime maximum benefits the policy will provide. In general, the older you are when you obtain long-term care insurance, the higher your annual premiums will be. Moreover, many long-term care policies include what are known as elimination periods, which define initial time periods of three months or longer during which you’ll be solely responsible financially for covering costs of care.

In addition, some states provide programs that assist with certain care needs for senior citizens. Nutrition programs deliver meals directly to many retirees’ homes, and transportation and personal-care assistance are aimed at making lives a little easier. Those services by themselves won’t address many of the major needs people have, but they can nevertheless help bridge some of the coverage gap in Medicare.

Medicare is a vital part of your long-term financial security in retirement, and it covers many different services. But to protect yourself against the needs for nursing and other long-term care, you’ll need to turn to alternatives to Medicare to give yourself the peace of mind that you’ll be able to cover those extensive costs.

MONEY Ask the Expert

How to Pick a Medigap Policy That’s Right for You

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Q: “I’m looking into Medigap insurance policies with very limited success. The information is very scarce. It is difficult to choose an insurance company. What criteria should I use to decide among carriers?” — Ray, Henderson, Nev.

A: Medigap, an insurance policy that supplements Medicare, helps pay for some of the medical costs that Medicare doesn’t cover, such as your co-payments, co-insurance, and deductible. Some policies even help with services Medicare doesn’t touch, like medical care outside the U.S.

You can choose from 10 standard Medigap policies, each named for a letter in the alphabet. The government mandates what features the 10 plans must offer, but the policies are sold through private insurers. (If you live in Massachusetts, Minnesota, or Wisconsin, the standard benefits on the Medigap policies sold in your state differ.)

Medigap Plan A is the most basic policy, while Plan F offers the most extensive coverage, picking up almost all of your out-of-pocket expenses. Plan F is also the most popular, accounting for 55% of plans sold, according to America’s Health Insurance Plans, the health insurance industry trade group.

The fastest growing Medigap policy, Plan N, is a newer option that has cost-sharing requirements but is typically less expensive than Plan F.

To shop for a Medigap plan, start with the Medigap policy search tool at the Medicare website. Enter your zip code, and you’ll see the standardized plans available to you, details about what they cover, the estimated costs, and a list of insurers selling those plans in your area. For price quotes, you’ll have to call each company directly.

Usually the only difference between same-letter policies is cost—and the price range can be shockingly large. According to a survey of rates by Weiss Ratings, the annual premium on a Medigap Plan F ranged from $162 to $5,674.

“I recommend that people get Plan F if they can afford it because it offers the most coverage,” says Fred Riccardi, client services director for the Medicare Rights Center. If you can’t swing a Plan F, pick the option that offers the most coverage within your budget.

Once you settle on a letter, you can shop on price alone. “Since the policy itself is standardized, premiums are really the only thing that will vary across insurance companies,” says Riccardi. “The only reason I see people go with a more expensive policy is if they prefer a certain insurance company.”

However, you do need to pay attention to the insurer’s pricing system too. Some plans are “issue age,” meaning the premiums rise with medical inflation. Others are “attained age” policies, with the price increasing each year with your age as well as medical inflation. You’ll also see “community rate” policies, which charge every policyholder the same premium regardless of age.

Attained age policies may appear to be the cheapest initially, but in the long run they could cost you more. “People should be aware that if they buy an attained age rated policy, their premiums will increase as they get older,” says Riccardi. “They may be better off considering a community rated or issue age rated policy if these options are available in their state.”

To get the lowest price and ensure that you won’t be denied, apply for a policy during the six-month open enrollment period that begins the month you turn 65, says Riccardi. Under federal law, insurers cannot deny you coverage during that window, and they must offer you the best available rates regardless of your health.

If you’re shopping for a Medigap plan outside of this window, you can be turned down or charged more for a pre-existing condition, unless you live in a state that offers extra consumer protections.

MONEY Health Care

Why a Serious Medical Condition Could Cost You Even More Next Year

Pill container spilling out money
Last Resort—Getty Images

Health insurance plans are hitting you with higher out-of-pocket costs for the specialty drugs you may need, a new study finds.

Americans with health coverage–including those who buy it through government insurance exchanges and Medicare beneficiaries–are likely to pay more out-of-pocket next year for so-called “specialty drugs,” which treat complex conditions, according to two studies from consulting firm Avalere Health.

More than half of the “bronze” plans now being sold to individuals through federal and state marketplaces for coverage that begins in January, for example, require payments of 30% or more of the cost of such drugs, Avalere said in a report out Tuesday. That’s up from 38% of bronze plans this year.

In “silver” level plans, the most commonly purchased exchange plans, 41% will require payments of 30% or more for specialty drugs, up from 27% in 2014.

As the cost of prescription medications rise, insurers are responding by requiring patients to pay a percentage of specialty drug costs, rather than a flat dollar amount, which is often far less. Insurers say the move helps slow premium increases.

But “in some cases this could make it difficult for patients to afford and stay on medications,” Avalere CEO Dan Mendelson said in a written statement.

While there is no standard definition of such drugs outside of the Medicare program, they are often expensive medications used to treat serious, chronic illnesses, such as multiple sclerosis, rheumatoid arthritis, hemophilia, some cancers and hepatitis C. While lists of specialty drugs can differ by insurer and by policy type, drugs can include arthritis treatments Enbrel and Humira, cancer drugs Gleevec and Tarceva, hepatitis C treatment Sovaldi, and MS drugs, Betaseron and Copaxone.

While they add up to only about 1% of all prescriptions written, specialty drugs account for 25% of spending on all drugs—an amount expected to rise rapidly, according to various studies.

An earlier Avalere analysis found that for the first time since Medicare’s drug program began in 2006, all of the stand-alone drug insurance plans place some drugs into specialty “tiers.” Two thirds of those plans require patients to pay a percentage of the costs of drugs in those tiers, rather than a flat dollar payment. Medicare plans can place a product into a specialty category only if the price negotiated with the drugmaker exceeds $600 a month.

Increasingly, health plans –including those offered to people with job-based coverage – require hefty payments, sometimes 20% to 40% or more of the total cost of medications that insurers classify as specialty drugs. That’s a change from the flat dollar payments of $10 to $30 or $50 that many patients have become accustomed to for other types of drugs.

Source: Avalere

There is a limit to how much patients must pay, but it’s often high: Most policies have an annual out of pocket maximum, which is often several thousand dollars.

The new Avalere study looked at plans sold in the federal exchange and in New York and California, which run their own marketplaces.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. This article was produced by Kaiser Health News with support from The SCAN Foundation.

MONEY Ask the Expert

Do You Really Need Medigap Insurance If You’re in Good Health?

140603_FF_QA_Obamacare_illo_1
Robert A. Di Ieso, Jr.

Q: We are in good health and have a Medigap Plan N for 2014. With same expected health in 2015, do we need anything more than Medicare A, B, and D plans? —Norbert & Sue

A: Medigap, a private insurance policy that supplements Medicare, picks up where Medicare leaves off, helping you cover co-payments, coinsurance, and deductibles. Some policies also pay for services Medicare doesn’t touch, like medical care outside the U.S.

This additional insurance is not necessary, but, says Fred Riccardi, client services director at the Medicare Rights Center, “if you can afford to, have a Medigap policy. It provides protection for high out-of-pocket costs, especially if you become ill or need to receive more care as you age.” (If you already have some supplemental retiree health insurance through a former employer or union, you may be able to skip Medigap; you also don’t need a Medigap policy if you chose a Medicare Advantage Plan, or Medicare Part C.)

If you purchase Medigap, you’ll owe a monthly premium on top of what you pay for Medicare Part B. The cost ranges from a median annual premium of $936 for Medigap Plan K coverage to $1,952 for Plan F coverage, according to a survey of insurers by Weiss Ratings. The median cost for your plan N was $1,332 a year.

Even if you didn’t end up needing your Medicap policy this year, however, think twice before you drop it.

If you skip signing up when you’re first eligible, or if you buy a Medigap plan and later drop it, you might not be able to get another policy down the road, or you may have to pay far more for the coverage.

Under federal law, you’re guaranteed the right to buy a Medigap policy during a six-month open enrollment period that begins the month you turn 65 and join Medicare, says Riccardi. (To avoid a gap in coverage, you can apply earlier.) During this time, insurance companies cannot deny you coverage, and they must offer you the best available rates regardless of your health. You can compare the types of Medigap plans at Medicare.gov.

You also have a guaranteed right to buy most Medigap policies within 63 days of losing certain types of health coverage, including private group health insurance and a Medigap policy or Medicare Advantage plan that ends its coverage. You also have this fresh window if you joined a Medicare Advantage plan when you first became eligible for Medicare and dropped out within the first 12 months.

Most states follow the federal rules, but some, such as New York and Connecticut, allow you to buy a policy any time, says Riccardi. Call your State Health Insurance Assistance Program to learn more.

Outside of one of these federally or state-protected windows, you’ll be able to buy a policy only if you find a company willing to sell you one.And they can charge you a higher premium based on your health status, and you may have to wait six months before the policy will cover pre-existing conditions.

MONEY Health Care

Why Obamacare Is Making Medicare Open Enrollment More Confusing

Tangle of Stethoscopes
Comstock Images—Getty Images

The time to sign up for an individual health insurance plan overlaps with the annual window for switching your Medicare plan. Here's how seniors can navigate this tangle of health care choices.

This is enrollment season for two huge public health insurance programs: Medicare and the Affordable Care Act health insurance exchanges. For older Americans, the overlapping sign-up periods can lead to confusion and enrollment errors.

Insurers offering Medicare and ACA policies have big money at stake, and consumers are subject to a blizzard of marketing messages. Annual enrollment for Medicare prescription drug (Part D) and Advantage (Part C) plans began Oct. 15 and runs until Dec. 7; shopping for healthcare policies in the marketplace exchanges created under the ACA began Nov. 15 and ends Feb. 15.

Consumer assistance groups report that some Medicare enrollees mistakenly think they must also enroll in the ACA exchanges. And for people with ACA plans who are turning 65, the transition to Medicare can be tricky. Here are some common questions about enrollment overlap, and answers aimed at helping older Americans keep things straight.

Q: What should I do about the ACA marketplaces if I’m already on Medicare?

Nothing. The policies sold on the exchanges are for Americans who don’t have coverage through an employer. And it is illegal for someone to sell you an exchange plan if the provider knows you are covered by Medicare. You can’t buy a Medicare Advantage, Medigap or Part D drug plan through the ACA marketplaces; to enroll in these plans, visit the federal government’s Medicare Plan Finder website.

Q: I bought health insurance this year on my state’s exchange, but I’m turning 65 in December. Do I need to shift to Medicare then?

It’s critical that you move to Medicare as soon as you are eligible. The enrollment window starts three months before your 65th birthday and ends three months afterward.

Failure to enroll will saddle you with expensive premium penalties. Monthly Part B premiums jump 10% for each 12-month period that you could have had coverage but didn’t—for life. That can add up: A senior who fails to enroll for five years ultimately would face a 50% Part B penalty—10% for each year. Penalties also are applied for late enrollment in Part D, under a different formula.

Q: When I shift into Medicare, can I just stick with the company that insures me in the ACA exchange?

You probably could do that; many of the nation’s biggest health insurers operate in both Medicare and the ACA exchanges. But brand loyalty isn’t advised here. Even if you’ve been satisfied with your provider, that company’s Medicare prescription drug plan may not offer the same coverage you had in the exchange. And the Medicare Advantage plan may not include the same network of providers or level of benefits.

Treat Medicare sign-up as a new shopping exercise. For starters, think about whether you want traditional fee-for-service Medicare or Advantage, a managed care alternative. Traditional Medicare allows you to see any health provider that participates in Medicare, but you’ll probably want to add a standalone prescription drug plan and a Medigap supplemental policy. With Advantage, you’ll be limited to in-network providers, but most plans have built-in prescription drug coverage and cap out-of-pocket spending.

Q: I qualified for tax subsidies in the ACA exchanges. Will those continue when I go into Medicare?

No. The ACA subsidies offset premium costs for households in a wide band of income, from 100% to 400% of the federal poverty level. This year that worked out to an annual income of between $11,490 and $45,960 for an individual, and $23,550 to $94,320 for a family of four.

Medicare enrollees can get assistance with premiums if they meet certain income and asset tests through the Medicare Savings Program. Another program, called Extra Help, can offset most or all prescription drug costs. The Medicare Rights Center’s website has a summary of these programs.

MONEY retirement planning

Five Takeaways on Retirement from the Midterm Elections

With Republicans controlling Congress, expect a push to cut Social Social and Medicare benefits—and maybe new ideas to encourage savings.

Retirement policy wasn’t on the ballot in last week’s midterm elections. But the new political landscape could threaten the retirement security of middle-class households.

With Republicans in full control of Congress, expect efforts to cut Social Security and Medicare benefits. And more Republican-controlled statehouses mean more efforts to curtail state and local workers’ pension plans. One positive note: Congress and the White House could find common ground on some promising ideas to encourage retirement saving.

Here are five policy areas to watch that could affect your retirement security.

SOCIAL SECURITY

The midterm results boost the odds that Social Security cuts will be in the mix if the brinkmanship over the federal debt ceiling or budget resumes.

Social Security does need reform. Its retirement trust fund will be exhausted in 2034, when revenue from payroll taxes would cover just 77% of benefits. Meanwhile, the disability program will be able to pay full benefits only through 2016. If Congress doesn’t act, 9 million disabled people will see their benefits cut by 20%.

Republicans have advocated higher retirement ages, less generous cost-of-living increases and means-testing of benefits. Some Democrats have fought for expansion of benefits and revenue for the program but haven’t been backed by President Obama or congressional party leaders.

How deeply could benefits be slashed? If previous conservative proposals are any guide, anywhere from 15% to 20%, with young people taking the biggest hit.

MEDICARE

The GOP has pushed Medicare reform plans that would “voucherize” the program, replacing defined benefits with a set amount of cash that beneficiaries could use to shop for coverage in a Medicare exchange. That would raise premiums for seniors in traditional Medicare by 50% in 2020 over current projections, according to the Congressional Budget Office.

AFFORDABLE CARE ACT

The ACA isn’t a retirement program, but it has helped older Americans by beefing up Medicare benefits covering older people who had trouble obtaining insurance and were too young for Medicare. This year the rate of uninsured 50- to 64-year-old Americans fell from 14% to 11%, according to the Commonwealth Fund.

The percentage would be smaller if the U.S. Supreme Court hadn’t given states an opt-out option on Medicaid—it has been expanded in only 27 states and the District of Columbia. Meanwhile, congressional Republicans continue to threaten funding, and the ACA faces a new Supreme Court threat. If the court rules that tax subsidies on marketplace premiums can’t be offered on the federal exchange, exchange insurance marketplaces will be on life support in all but 13 states with their own exchanges.

PENSIONS

Republicans will control 31 governors’ offices and 30 state legislatures, the most since the 1920s. That means we can expect the attack on public sector pension benefits to accelerate.

The National Association of State Retirement Administrators and the Center for State & Local Government Excellence reviewed pension reforms by 29 states this year and found reductions in annual benefits ranged from 1.2% (Pennsylvania) to 20% (Alabama); the average across all states was 7.5%.

RETIREMENT SAVING

A grand bargain on the federal budget could limit pre-tax contributions to 401(k) accounts, an idea floated regularly in tax reform discussions. And ideas aimed at helping lower-income households save for retirement could gain ground. The Obama Administration has asked Congress to create a national automatic IRA option and is rolling out a limited version called the MyRA.

Meanwhile, Senator Marco Rubio (R-Florida) has called for a government-sponsored 401(k)-style account for Americans who don’t have a plan at work. He would like to open up the federal Thrift Savings Plan to private-sector workers. That’s attractive because the TSP boasts low costs, a short and easy-to-understand set of investment choices and options to convert savings into an annuity stream at retirement.

Another idea I like: the “baby Roth.” The plan’s architect projects that an initial contribution of $500 to an infant’s Roth IRA, with subsequent annual contributions of $250, would grow to $131,800 at age 65, versus $35,300 for an account started at age 25.

It’s disappointing that few candidates campaigned on ideas that would help the middle class build retirement security. Democrats could have boasted about how the ACA is helping older Americans. And polls show that expanding Social Security and keeping Medicare strong are winning issues across partisan divides and demographic groups.

MONEY retirement income

Retirement Withdrawal Strategies That Can Pay Off Big

To figure out the right pace for your retirement withdrawals—and to avoid ending up in higher tax brackets—start planning before you stop working.

Having your own tax-deferred retirement account is a bit like having one of those self-titrating morphine buttons that hospitals use: Press it whenever you need quick relief.

But once you’re retired and able to tap your 401(k) or individual retirement account (IRA), it’s not easy to titrate your own doses of cash. Withdraw too much, and you use up your nest egg too quickly; too little, and you might unnecessarily crimp your retirement lifestyle.

Overlaying the how-much-is-enough question are several finer points of tax planning. Because you can decide how much money to pull out of a 401(k) or individual retirement account, and because those withdrawals are added to your taxable income, there are strategies that can help or hurt your bottom line.

That’s especially true for early retirees trying to decide when to start Social Security, how to pay for health care and more. Here are some money-saving withdrawal tips.

CURB TAXABLE INCOME

If you are buying your own health insurance via the Obamacare exchanges, keep your taxable income low to qualify for big subsidies, advises Neil Krishnaswamy, financial planner with Exencial Wealth Advisors in Plano, Texas.

“It’s a pretty substantial savings on premiums,” said Krishnaswamy.

Here’s an example using national averages from the calculator on the Kaiser Family Foundation web page. Two 62-year-old spouses with annual taxable income of $62,000 would receive a subsidy of $8,677 a year, against a national average premium of $14,567. If they took another $1,000 out of their tax-deferred account and raised their taxable income to $63,000, they would be disqualified from receiving a subsidy.

Not every case may be that dramatic, but it’s worth checking the income limits and available subsidies in your own state.

DELAY BENEFITS

If you retired early, consider taking out extra money to live on and delaying Social Security benefits until you are older. Withdrawing money from retirement savings hurts. You not only lose the savings, you lose future earnings on those savings. And in most cases, you have to pay income taxes on withdrawals from those tax-deferred accounts.

But Social Security benefits go up roughly 8% a year for every year you don’t claim them. And even after you claim them, they rise with the cost of living and are guaranteed for life. When you draw down your own savings to protect a bigger Social Security payment, tell yourself you are buying the cheapest and best annuity you can get.

PLAN IN ADVANCE

Plan ahead for mandatory withdrawals. In the year you turn 70 1/2, you have to begin drawing down your tax-deferred IRAs and 401(k) accounts and paying income taxes on those withdrawals. Unless you expect to be in the lowest tax bracket at the time, it makes sense to start withdrawing at least enough every year before then to “use up” the lower tax brackets.

For single people in 2014, you’re in a 10% or 15% marginal tax bracket until you make more than $36,000 a year. For married people filing jointly, that 15% bracket goes up to $73,800. It’s a lot better to pull out that money in your 60s and use up other savings to live on, than it is to save it all until you are 70 and then withdraw large chunks at higher interest rates.

GET A GOOD ACCOUNTANT

You may want to use early years of retirement to take the tax hit required to move money from a traditional IRA into a Roth IRA that will free you of future taxes on that money and its earnings.

You may pull a lot of money out of your account in one year and spend it over two or three years, to keep yourself qualified for subsidies in most years.

You may titrate your withdrawals to keep your Medicare premiums (also income linked) as low as possible.

The best way to optimize it all? Get an adviser or accountant who is comfortable with a spreadsheet and can pull all of these different considerations together.

Related:

When do I have to take money out of my 401(k)?

How will my IRA withdrawals be taxed in retirement?

Are my Social Security payouts taxed?

MONEY Health Care

Why You Should Forget About Ebola and Get a Free Flu Shot Instead

Flu Shot Sign
Getty Images

Americans are nearly as worried about Ebola as they are about catching the flu. But influenza is the risk you should pay attention to. And you probably don't need to spend a penny to protect yourself.

Take a break from worrying about Ebola and get a flu shot this fall. While the Ebola virus has so far affected just four people in the United States, tens of millions are expected to get influenza this season. More than 200,000 of them will be hospitalized and up to 49,000 will likely die from it, according to figures from the Centers for Disease Control and Prevention.

A new HuffPost/YouGov poll of 1,000 adults found that the flu is perceived as only slightly more threatening than the Ebola virus, however. Forty-five percent of people polled said that the flu posed a bigger threat to Americans than Ebola, but a substantial 40% said it was the other way around. Fifteen percent said they weren’t sure.

“Ebola is new, mysterious, exotic, highly fatal, and strange, and people don’t have a sense of control over it,” says William Schaffner, a professor of preventive medicine and infectious disease at Vanderbilt University.

Influenza, on the other hand, is a familiar illness that people often think they can easily control, Schaffner says. “They think, ‘I could get vaccinated, I could wash my hands’ and prevent it.”

Yet that familiarity may lead to complacency. Flu shots are recommended for just about everyone over six months of age, but less than half of people get vaccinated each year.

Now there’s even more reason to get a shot. The health law requires most health plans to cover a range of preventive benefits at no cost to consumers, including recommended vaccines. The flu shot is one of them. (The only exception is for plans that have been grandfathered under the law.)

The provision making the vaccine available with no out-of-pocket expense is limited to services delivered by a health care provider that is part of the insurer’s network.

Depending on the plan, that could include doctors’ offices, pharmacies, or other outlets.

Medicare also covers flu shots without patient cost sharing.

Kaiser Health News is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente.

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