Alyssa Gonzales, Medicare Insurance Broker

Answer: The question is, as a senior, what should I know about the differences between original Medicare and Medicare Advantage before I choose? So that's a loaded question, but I'm gonna try to break it down quickly.

Original Medicare is going to be Part A and Part B as your primary insurance. So that's that red, white, and blue card that says Part A and Part B. Normally, you will have a Medicare supplement, also known as a Medigap plan, as a secondary, sort of like a backup. So they're gonna build your primary, which is original Medicare, then build your secondary. And that's usually the way it goes in terms of creating a holistic hospital and medical plan, a primary and secondary.

Now, because you have original Medicare as your primary, you're not working within the confines of an actual insurance company. You don't have networks. You don't have the things like you would have on the Medicare Advantage side, right? So this is the opposite side of the road. Medicare Advantage does replace original Medicare, so you will be working from a company's HMO or PPO plan. It's just another managed care plan that follows the Medicare rule book.

I can go in-depth about this, but to keep it short, that is the difference. Medicare Advantage, also known as Part C, is a managed care plan that comes in the form of HMO or PPO plans. And then you've got original Medicare, which is Part A and Part B, normally served up with a Medicare supplement as a secondary. Good luck!

Answer: The question is, how do I find local dentists that take my Medicare coverage? You can do this in two different ways. Number one, if you're on a plan currently, you want to look at your summary of benefits and see where you need to go within the company's website that is your insurance. You can just do a provider search very easily. My personal favorite is by calling your dentist and asking them this exact question. This is very important because more and more dentists say they accept insurance, but they accept the insurance as an out-of-network provider. They'll accept all PPO plans but bill as an out-of-network provider. This is very, very important because if you call them and they say, "Do you take Aetna? Do you take Sigma? Do you take Mutual Omaha?" they'll say no because they're technically not in network, but they will accept on an out-of-network basis. So the best way to go about this is, number one, call your dentist. And number two, when you're looking for a dental policy, a standalone dental policy, you want to make sure it's a PPO. If your dental plan is within a Medicare Advantage plan, yes, you're going to get the most bang for your buck through the plan's resources. So you want to go to your specific plan on the company's website and look up the dental providers to find a provider.

Answer: How can my Medicare plan still meet my needs if my health care changes? The answer to this question is to remember to do your annual reviews. That's what they're there for. That's what brokers like myself are for. So whether you use yours or inquire to get in touch with me, we want to go through every single year. What's your rate? What's your plan's network changes? What are your health changes? Do you still take the same medications? Think of this as just an oil change for your health care. You want to do it every year just like you change your oil every 2,000 miles. Same thing. Good luck.

Answer: Regulations help keep the industry coloring inside the lines, but we need to address the egg before the chicken. I believe having advocates for both the beneficiary (you) and the broker (me) in front of lawmakers would create more balanced and effective policies.

Answer: Yes losing employer or union coverage qualifies you for a Special Enrollment Period. You generally have 8 months to enroll in Medicare Part B and 63 days to enroll in a Part D or Medicare Advantage plan without penalty. Don't wait. Processing times can very, and you don't want to be left holding a bag full of penalties!

Answer: Usually yes, unless you’re within your Medigap Open Enrollment Period (6mo from Part B start date) or have a Guaranteed Issue right (losing employer or union coverage, your Medicare Advantage plan leaving your area, or moving out of your plan’s service area. ). Outside of those times, yes, the insurance companies can require what's called underwriting and decide to approve or deny coverage based on the answers to the questions they ask.

Answer: Some parts of Medicare are already privatized through Medicare Advantage and Part D plans, but full privatization is unlikely soon. The program has strong public support, and major changes would face heavy opposition. Which is why it's very important to review your plan every year during Annual Enrollment Period October 15th to December 7th.

Answer: If you're turning 65 and still working with creditable employer coverage, you might not need to enroll in full Medicare just yet. My rule of thumb is to always compare group coverage to what Medicare would offer you. I find that most folks are shocked at what they learn! After comparing coverages, you are able to make decisions based on facts and not emotions. Compare things like cost of insurance, deductible, and max out of pocket to start with!

Answer: Absolutely. The MOOP is the most you’ll pay out-of-pocket in a calendar year for covered services under a Medicare Advantage plan... after you hit that cap, the plan pays 100%. In my experience, it's a lifesaver if something major happens.

Answer: You can qualify for Medicare if you've been on Social Security Disability Insurance (SSDI) for 24 months, have ALS (you get Medicare right away), or have End-Stage Renal Disease (ESRD) and meet certain treatment criteria. It's not super common but you have options if you have one of the mentioned conditions.

Answer: Well, it’s a solid start.... but it doesn’t cover everything, so most folks end up pairing it with a Medigap plan or Medicare Advantage to fill in the gaps (and avoid surprise bills). Medicare Part B covers doctor visits, outpatient care, preventive services, lab work, durable medical equipment, and things like physical or occupational therapy.

Answer: Don’t panic! You’ve got the right to appeal. Start by reading the denial letter, then follow the instructions to file a Level 1 appeal, usually just a simple form and a doctor’s note explaining why the service is medically necessary. A whopping 81.7% could be fully or partially overturned(Kaiser).

Answer: People are shocked to find out that Medicare doesn’t cover routine dental care, no cleanings, fillings, crowns, or dentures. You can get dental in most Medicare Advantage plans and/or seek private coverage if you want to cover this exposure.

Answer: Yup ..... it's real talk! Starting January 1, 2025, anyone with a Medicare Part D plan (or Medicare Advantage with drug coverage) will pay no more than $2,000 in out‑of‑pocket costs per calendar year for covered prescriptions this includes deductible, copays, and coinsurance. Once you hit that cap, you’ll have catastrophic coverage and pay $0 for the rest of the year.

Answer: Very common issue and to answer this YES, Medicare Part B can help cover medically necessary occupational therapy when it’s ordered by your doctor. Just know there’s an annual threshold, once you hit that amount, your provider may need to confirm that ongoing therapy is still medically necessary for coverage to continue.

Answer: Yep, your Medicare deductible can change each year! It's set by the government and usually goes up just a bit to keep up with inflation. I always keep an eye on it during Annual Enrollment Period which is October 15th to Dec 7th of each year.

Answer: I hear this all the time! "You can only change your Medicare Supplement plan during the Annual Enrollment Period (AEP)."

That’s not true! You can apply to switch your supplement plan any time of year — as long as you can pass medical underwriting (in most states).

If you are wanting to go from a Medicare Advantage Plan to a Medicare supplement outside of Annual Enrollment Period then you need to make sure you have a qualifying Special Enrollment Period (SEP) before you begin.

Answer: This is a hot topic! Medicare mainly covers treatments that have strong clinical evidence behind them, but many seniors find relief through alternative options too. Medicare is evolving! It would be great to see more coverage for alternative medicine! Stay tuned!

Answer: You bet! The key words are preventative and that it's medically necessary. It’s usually covered once every 24 months, or more often if medically needed. As long as your provider accepts Medicare assignment, you won’t pay anything out of pocket.

Answer: You’ll be automatically enrolled in Medicare Parts A and B, no need to sign up yourself. Your Medicare card will arrive in the mail a few months before your 65th birthday.

Answer: The question is how do you educate clients who are completely new to Medicare? Welcome to the club. This is the first thing that I say, and then I encourage them to attend a Medicare 101 webinar seminar. An in-person event. You want to treat this as something that, hey, you don't really major in. You didn't go to work for this. You didn't get a degree in this. You want to seek a professional and attend multiple events. Whether it be online, I personally do a Medicare 101 webinar. I'd love to send you information about it. Just get in contact with me. I'll send you the recording. But also attend other events. This is how you get to know the broker, the person behind the recommendation. And you get to know the person so that they can get to know you, and then they can recommend a plan based on your specific needs. Customization is the best approach to Medicare. But first, you have to approach it from an educational point of view. So just like anything, you want to learn about it a little and then speak to a professional about it. Good luck.

Answer: I wish every senior knew that the 'best' Medicare plan isn’t the same for everyone... it’s the one that fits your specific needs and budget.

Too many people pick a plan based on what their neighbor has or just go with the cheapest option, only to find out later that their doctor isn’t covered or their medications cost way more than expected.

Take the time to compare your options, ask questions, and make sure you’re choosing a plan that actually works for you. And if you're feeling overwhelmed, talk to an expert, because guessing your way through Medicare can be an expensive mistake!