Affluent Americans near retirement are “terrified” about the cost of health care, but they aren’t discussing it with their advisors, according to a survey by the Columbus, Ohio-based Nationwide Retirement Institute.

Nearly three-quarters of U.S. adults with $150,000 or more in annual income and over 50 years old list “out-of-control” health-care costs among their top fears in retirement. Yet 48 percent of the survey respondents who had retained a financial advisor were not discussing health-care costs with their advisor.

Most of the affluent survey respondents, 64 percent, said they were “terrified” about the potential impact of health-care expenses on their retirement plans.

“This year was the first year we looked at affluent adults and we were surprised to see that they still listed health care as one of their top fears,” said John Carter, Nationwide’s president of retirement plans business. “More than half of them were unaware of what their health-care costs would be moving forward.”

Carter said that this is the fifth year Nationwide has run a survey connecting retirement planning and health-care expenses.

More often than not, the respondents were avoiding health care conversations because they felt it was too personal an issue for discussion, as it involves both health and finances. One-third of the survey takers had not had a conversation with anyone about their medical expenses.

Still, 38 percent of the respondents who had engaged with an advisor said that they did not discuss health-care expenses because their advisor did not know enough about health-care expenses in retirement, indicating that advisors may be missing both a key planning topic and an opportunity to deliver more value for their clients.

“When we look across the years of the survey, we find that the balance of people who have talked to an advisor about this issue is going up, and more than half of our respondents believe that it is important to discuss this issue with an advisor,” said Carter. “I think we have to help consumers ask better questions of their advisors, like ‘how much should I expect to pay in healthcare expenses in retirement?’—it’s simple and specific to health care, and then the advisor can discuss some ways to save for health care to meet that need.”

Despite their income, affluent Americans are highly likely to look to federal entitlement programs to help cover the cost of medical care. Two-thirds of the respondents said that they would use Medicare to help pay for health-care costs, and 63 percent are planning to use some of their Social Security benefits. More than two-fifths, 42 percent, said that they would give all of their assets away to their children so that they could be eligible for Medicaid-funded long-term care.

The survey found that 59 percent were unsure what their annual health-care expenses might be. The remaining respondents estimated $22,849 in annual health-care expenses for themselves and their partners.

Advisors may want to brush up on their Medicare knowledge. Nearly nine in 10 of the survey’s respondents said that they are enrolled or they plan to enroll in Medicare, while 72 percent of the respondents said that they wish they better understood Medicare.

“We’re hearing that people want to understand their Medicare coverage better, and we have a responsibility to start to meet them where they need information,” said Carter.

Older, affluent Americans still hold misconceptions about Medicare, including not understanding that parts of the program are not free and that coverage does not cost the same for everyone. Many need help understanding how and when they should sign up for coverage, according to the survey.

Future retirees are more likely to rely on multiple options to cover health-care costs than current retirees—while 59 percent of currently retired respondents said that they would use a wider array of resources like Medicare to help pay their expenses, 71 percent of future retirees said that they would take a broader approach.

Despite their access to more resources like personalized financial advice, most of the survey respondents, 60 percent, could not cover more than $5,000 in unplanned expenses. Nearly one in four of the respondents were unprepared for unexpected expenses of more than $1,000. Most respondents were  planning to use their disposable income to cover unplanned expenses.

Health savings accounts (HSAs) may present another opportunity for advisors. While half of the survey had access to an HSA, only 30 percent were saving in them—and only 10 percent were using their HSA as a long-term savings and investment vehicle.

“We’re finding that most people are not leveraging these as a savings vehicle, and this becomes a natural conversation to have with clients and consumers who are retirees and pre-retirees,” said Carter, who suggested that plan advisors and sponsors may need to implement behavioral savings mechanisms employed in 401(k)s, like auto-enrollment and auto-escalation, for HSAs.

Advisors may also want to engage more closely with family caregivers. While Nationwide’s sample of more than 500 caregivers were acutely more aware than others in the survey of the cost and potential impacts of health care expenses, they were also less likely to be planning and saving for those expenses.

Nationwide’s survey was conducted in February among 1,007 U.S. adults aged 50 and older, and 522 U.S. caregivers aged 50 and older.