Andrew Kramer, Medicare Insurance Agent

Answer: What's the meaning of "good-what's going on?" No matter what plan you have - original Medicare with a supplement, Medicare Advantage PPO or HMO, you just can't get some kind of major medical, i.e. MRI, surgery, etc, covered without getting prior authorization! Think about it rationally... can you just walk into an imaging center and say, "I want an MRI of my knee and I want my insurance plan to pay for it?" A request for "auth" to your plan, must have documentation from your provider for the need for, in this case, a knee replacement. My clients often get referrals and auths mixed up. They are not the same!

Answer: No! Part A & B are not enough, unless you don't mind having to pay the 20% that Medicare does not cover for a hospitalization, and the Part A hospital deductible! Speak with a licensed, independent agent who can go over Advantage plans vs a supplement.

Answer: Medicare does not cover Silver Sneakers, but most Advantage plans do cover Silver Sneakers. Look at the summary of benefits of your plan. Some supplements give you the option of adding Silver Sneakers for a cost.

Answer: Your Medicare Advantage plan covers you each time you are in the hospital, at the co-pays of your plan. Without knowing your hospital co-pays, it's not possible to answer your question, and it also depends on the cost of the hospital indemnity plan. But generally speaking, such plans are not needed for those on Advantage plans. Those are usually taken by under-65'ers who have very large out-of-pockets for a hospitalization.

Answer: There are 2 kinds of agents - Captive and Independent. A Captive agent works for only one Advantage plan, therefore can only show a prospective client plans from that company and can only get paid commission from that company. An Independent agent can be appointed with many companies, therefore that agent's only incentive is to enroll the client in the most suitable plan for the client.

Answer: I do not do remote enrollments unless the client is already my client and we met before and they moved to another location in my state. I don't believe in doing remote enrollments, definitely to another state.

Answer: Medicare does not cover optometrists, i.e. exams for eyewear. But Medicare does cover ophthalmology. However, diabetics get enhanced optometry coverage as well. And to say that "seniors are paying too much for optometry," makes no sense since a typical optometry visit costs about $75.

Answer: Yes of course! But it must be deemed "medically necessary" in order to get the authorization for such a procedure. An orthopedic Dr would do that.

Answer: This is because Advantage plan co-pays can change from one year to the next. You received your ANOC (Annual Notice of Change) back at the end of Sept. Didn't you look at it?

Answer: Actually, your agent should have reached out to you in the AEP (Annual Enrollment Period) from Oct 15 to Dec 7 to do that with you! But it's not too late. We are in the OEP (Open Enrollment Period) from Jan 1 to Mar 31, if you wish to change your Advantage plan.

Answer: Original Medicare cannot pay for groceries. Some Medicare Advantage plans have "dual" plans, meaning a plan that combines Medicare + Medicaid. Those plans do include a debit card that can be used to buy food. But starting in 2026, Medicare requires you to also have at least 1 chronic condition to qualify for buying food, i.e. HBP, cholesterol, diabetes, etc. 95% will qualify. But again, you must have both Medicare and Medicaid! There are also some chronic plans (heart disease, diabetes, pulmonary) that also offer a debit card for food, but a limited $ amount, i.e. $35 to $65. Speak with your agent.

Answer: In order to find out, you need to, #1 download the 2026 Part D plan you have, or the Advantage plan, and find the place that shows the co-pays according to the Rx Tiers, typically 1, 2, 3, 4 and 5 (sometimes there's a Tier 6); then #2, you need to download the Rx formulary of that plan, then search your Rx names and note the tiers of each. There might also be an RX deductible, typically for Tiers 3-5, or only 4-5, or none, depending on the Part D plan. Now you can calculate your Rx costs. You can also call your agent and have him/her do that for you! You do have an agent, right? :)

Answer: That's a broad question. If you mean recovery in a skilled nursing/rehab facility, then yes, Medicare covers 20 days/year at no charge. But to trigger that coverage, you must have a minimum hospital stay of 3 overnights.

Answer: Chiropractic coverage is specified by Medicare and cannot be made broader than the rules of Medicare. Coverage is specified as "subluxation."

Answer: You should listen to neither of them! Why? Because they are not health insurance agents who specialize in Medicare! If you want a valid comparison of being on original Medicare, compared to an Advantage plan, speak with an experienced, independent agent.

Answer: Why do you think Medicare focuses only on treatment? Isn't the purpose of your annual physical a focus on prevention, to catch issues before they become serious? It turns out that 65% of Medicare recipients who are either on original Medicare, or a PPO Advantage plan, do NOT get their annual physical, rather they jump to specialists, thinking they get better care from a specialist rather than their PCP! And their health is worse than those on HMO Advantage plans whose PCP requires them to get their annual physical. So whose fault is it that many Medicare recipients are getting treatment rather than prevention?

Answer: All Advantage plans follow original Medicare and do not offer additional health benefits beyond what original Medicare offers. So the answer to your question is, no.

Answer: This rule is very well known by a licensed health insurance agent who specializes in Medicare plans. Did you contact one when you turned 65? Also, you receive the Medicare book from social security when you turn 65, and every year thereafter. The information is there for you to read it.

Answer: Only a certified financial planner can give you correct advice as to when to claim your Social Security benefits, based on your finances. Do not take advice from family or friends!. You can also look up various options on the Social Security website, or call them.

Answer: All hospitals are in-network if you go to the ER and then get admitted. But if you have a pre-planned surgery, the Dr doing the surgery will choose the hospital that he prefers. You cannot have a say in that. But if there are few hospitals in your area and you have one that you know a Dr would choose to have surgery in, then change your Advantage plan to one that includes that hospital.

Answer: No, original Medicare does not cover such extras. There are some Advantage plans which include OTC benefits, and some include wearable devices in their catalogs.

Answer: I don't understand the word "private" as it relates to hospitals. All hospitals are owned by various companies and are therefor "private." To my knowledge, other than VA hospitals, no hospitals in the US are government owned. And all take Medicare, but not all take all Advantage plans, unless you enter a hospital through the ER, in which case all hospitals are in-network for your plan.

Answer: It sounds like your friend is on an Advantage plan and you are on a supplement plan. Many Advantage plans have $0 monthly premium, whereas supplements have a premium. Nothing is random! Both supplements and Advantage plans change according to the county you live in. You need to speak with a local (not out-of-state) health insurance agent who specializes in Medicare plans to learn more.

Answer: Yes, that is correct. Supplements are "secondary" to Medicare and cover part or all of the 20% that Medicare does not cover. Advantage plans are not considered as secondary to Medicare because they take over your Medicare coverage and become primary insurance. They are Part C of Medicare, which combine Parts A, B and usually D, into one, comprehensive plan, that is equal to Medicare, but has a Dr network. Only use a local agent to help you with this!

Answer: First, never listen to friends. Are they insurance agents? Nope. Find a trusted and local agent, not out-of-state. That agent will ask for her Dr's and can check the various plans to see which, if any, accept all her Dr's.

Answer: First of all, CMS (that's the official name for Medicare) does not "market." Any calls you receive, (which are illegal!), postcards, or TV ads are 3rd party organizations trying to get your business. As for their "tricks" to get your business? Many! Just don't deal with any of those. Always trust your local agent. And never use an out-of-state agent.

Answer: Medicare does not "fall short" it simply does not cover long term care. You need to pay out-of-pocket for assisted living or any kind of long term care.

Answer: You are not giving clear guidance as to what Medicare coverage you have, original Medicare with a supplement, or an Advantage plan, so I will reply to both.

If you have original Medicare with a supplement, you can change the supplement anytime you want, but that would be a bad idea because you will be subject to health underwriting, plus pay a higher premium due to your older age. If you are asking about your separate Part D plan, the only time you can change that is during the Annual Enrollment Period from Oct 15 to Dec 7.

If you have an Advantage plan, you can change your plan twice a year - from Oct 15 to Dec 7, the Annual Enrollment Period, and/or during the Open Enrollment Period from Jan 1 to Mar 31.

If you qualify for a chronic Advantage plan, you can change once, anytime during the year.

If you have full Medicaid, you can change your Advantage plan anytime during the year.

Answer: Sorry to hear what you and your mother are going through. Medicare does not cover long-term care, therefore Advantage plans do not cover long-term care.

Answer: Advantage plans are, by law, required to post "legit" benefits. If you want to check, then go online to the plan's website and download the summary of benefits of the plan(s) you are interested in.

Answer: This is not an easy question to answer because Medicare Advantage plans vary from state to state and county to county. And the cost of Medigap plans also vary in the same way, as do Dr networks on Advantage plans.

Answer: You will need prior auth's no matter what plan you are on, Advantage HMO, PPO or original Medicare! Think about it... could you walk into an imaging center and ask to get an MRI and have your Advantage plan pay for it? You have always needed an auth. What you don't need on a PPO is a referral to see a specialist, but that's it.

Answer: You have not given enough info to properly answer your question. Look at the service area of your plan to see if the new county is still in the service area. If it's not, then you must change your plan within 3 months of your move. In any case, you should be either contacting your agent, or the plan directly, for a proper answer.

Answer: It seems to me that whoever your agent was, he/she did not explain to you the meaning of your Advantage plan. It is a replacement for original Medicare. If you have an HMO Advantage plan, you cannot go out of network except in the case of emergency outside your network area - any urgent care and the ER of any hospital. If you have a PPO Advantage plan, then you can go out of network to see any Dr and pay the higher co-pay. But you can NEVER give them your Medicare card! Why? Because if they bill to original Medicare, they will not pay and it will go to collections! Your payer of all Medicare expenses is your Advantage plan only!!

Answer: This is a common misconception that Medicare offers some kind of long-term care. It does not! Medicare only offers a small amount of home health care after an illness or hospital stay, but it's typically not more than about 100 hours/yr. So the answer is, Medicare does not fit into the planning of long-term care. Long-term care plans can be purchased but, #1 they are expensive #2 they can increase in price over the years and, #3 they must be purchased long before age 65.

Answer: #1 You find a qualified and experienced Health Insurance agent who specializes in Medicare plans and is an independent agent, meaning he is contracted with multiple Advantage plan companies in your area. #2 You meet with her/him and go over all your important Dr's, Rx's and the co-pays of the plans, in order for you to select the plan which best suits you. And you do all this well before Dec 7th.

Answer: There is no such terminology as a "Medicare advisor." There are licensed health insurance agents that must be appointed in the state you live in, who also specialize in Medicare plans. They must also be appointed with the Medicare plans they represent. And of course you can meet with one on behalf of your parents, but unless you have legal authority to act on their behalf, you cannot sign them to any plan.

Answer: You can get the same travel coverage with an Advantage plan, either HMO or PPO. All Advantage plans enable you to go to any urgent care in the US, and the ER of any hospital in the US for the co-pays of your plan. You also have $25,000 for foreign travel emergency.

Answer: Not sure what you're referring to as "coverage gaps?" Do you mean the 20% that Medicare does not pay? Or the Part B deductible, which this year is $257? If that's what you mean, those are not coverage gaps, rather financial cost sharing. Coverage gaps would infer illnesses that Medicare does not cover, and that's not the case.

Answer: This is an easy one to answer! DO NOT call TV ads; DO NOT sign and return post cards to so-called Medicare agencies; DO NOT answer the phone to anyone who calls you saying they want to update you about your plan. No such updates exist! ONLY deal with your agent, no one else!!!

Answer: Who says that Medigap pans are better for long-term coverage? There is no "1-size fits all" for Medicare plans. The choice between a Medigap plan and an Advantage plans depends on a number of factors, including: state and county where you live, Dr's you want to be able to see, money you have available. It's not a good idea to base such an important decision on reading generalized articles you find online that do not reflect those factors. It's important to use a local and experienced agent!

Answer: Yes, Medicare and also Advantage plans, cover limited Home Health Care. Because remember, Medicare does NOT cover LTC (Long Term Care). Home Health Care will require an authorization from a Dr, and it's limited, exactly how much is not stipulated in writing. Except some Advantage plans do stipulate, for example, the Human Gold+ H1036-062, 80 hrs/yr, with a minimum of 4 hrs/visit. And typically there needs to be a qualifying event to trigger Home Health Care, i.e. an illness or injury.

Answer: Hospice if provided by Medicare Part A. Both Original Medicare and all Advantage plans will provide hospice.

Answer: Most Medicare Advantage plans cover a free hearing test, and an allowance or co-pays for hearing aids. You can check what your plan offers in their Summary of Benefits book, which was provided to you when you joined. And you can check for 2026 by looking at the ANOC (Annual Notice of Change) that was sent to you by Oct 1.

Answer: Hopefully you've had employer insurance, AND 20 or more employees are on that insurance! If that's the case, you will not be penalized for not signing up for Part B when you turned 65. You will need to obtain the CMS forms for your employer to confirm you had their insurance. And then submit that form, and the personal CMS form to a local SSA office.

Answer: The worst Medicare related decision that someone can make is if they choose a supplement (not an Advantage plan) and base their decision on the plan with the lowest premium, without investigating that companies rate history!

Answer: Who says people are unhappy with Medicare Advantage plans? Are you reading general articles that are "click-bait?" I have 90% of my clients on Advantage, including me, and none are unhappy! Perhaps other agents don't explain the plans to their clients, or some are using call-centers to enroll, which do a terrible job.

Answer: Who told you this nonsense? If a doctor wants you to get a CT scan and correctly documents your need for it, of course you can get that!

Answer: Dental and vision coverage are included in most Medicare Advantage plans. But if you want to stay in original Medicare, you will need to buy a separate dental and vision plan, since that coverage is not part of original Medicare, unless it's related to an illness, i.e. ophthalmologist.

Answer: Your annual wellness visit is free on all plans - HMO, PPO and original Medicare. There is no change to this feature of plans.

Answer: Yes, this is normal, it's a requirement of CMS to document the plans to be discussed and does not enroll you in anything. Call centers are NOT exempt from this rule! But my advice is to NEVER deal with a call center! You will never get customer service form them after! Only use a local agent, not even an agent out-of-state!

Answer: Sure, quite simple. The AEP (Annual Enrollment Period) is from Oct 15 to Dec 7. That's when those on Advantage plans and stand-alone Part D plans can change their plan, with an effective date of Jan 1st. Also those on Advantage plans can choose to go back to original Medicare, but may or may not qualify for a supplement depending on their health. They can also sign up for a Part D plan. But without having a supplement, they would be subject to paying 20% on original Medicare.

Then Jan 1 to Mar 31 is the OEP (Open Enrollment Period) when those on Advantage plans can change their plan, or again, go back to original Medicare. Those on original Medicare and stand-alone Part D plans cannot make a change during the OEP, they are locked in for the year.

Answer: Wow, this is old news, took affect at the beginning of this year. Yes, Rx's are capped at $2,000, instead of the prior $8,000. That was explained to you in 2024 when you got the ANOC of your plan for 2025, best to read the ANOC.

Answer: Yes, there are changes! But no agent is permitted to explain anything to you before the AEP starts on Oct 1st. Look for your ANOC to explain changes to your plan, then call your agent for options, if necessary.

Answer: Discount cards cannot be used with those on Medicare, it says exactly that right on the cards. Also, be careful NOT to use GoodRx or other discount programs because your Rx costs will then not be counted towards your $2,000 TROOP (i.e. max-out-of-pocket). The only time I suggest to my clients to use GoodRx is if the plan has placed the Rx in a Tier 3, which would incur the Rx deductible, but the Rx is actually an inexpensive generic, i.e. Valacyclovir, Hydrocodone/acetaminophen, Synthroid and some others. There are some state pharmaceutical programs that can be used occasionally.

Answer: No, there is no form to state that. Just be careful. The rule from Medicare is that there must be a minimum of 20 people ON the group health plan, so that when you do sign up for Part B, you will not be penalized. When you do sign up for Part B, there's a CMS form that will go to your employer stating that you did have group health insurance, which you will then submit to the SSA, along with your personal CMS form.

Answer: I don't understand why anyone would be surprised by bills on an Advantage plan because you get the summary of benefits which lists every co-pay and occasional co-insurance. So if there's a surprise, it would appear that document is not being read.

Answer: Medicare recipients always have a choice to buy a Medigap insurance policy. No one is forcing anyone into Advantage plans. And Advantage plans are not taking over. If more Medicare recipients choose Advantage plans, it's simply their choice.

Answer: Medigap is a supplement insurance policy to original Medicare, not a network of providers. So there is no such thing as out of network, unless the client is using a provider who does not accept Medicare (rare), in which case the Medigap policy would not pay anything.

Advantage plans are either HMO, HMO-POS and PPO. A PPO has out-of-net coverage with a higher co-pay, some HMO-POS plans also do, but HMO's do not.

Answer: You will not incur a late enrollment penalty if the following 2 conditions are met. #1 At your wife's employment, 20 or more employees are on the group health plan. Not just 20 employees. But 20 on the group plan! #2 The part of that plan that covers Rx's, meets the minimum requirements of Medicare drug plans. Be careful with that because Medicare Rx plans have a $2,000 cap.

Answer: Well no one is going to stop anyone helping pay your premium or co-pays, depending what plan you have. There is nothing illegal about that!

Answer: Not exactly. Advantage plans take over Medicare from CMS. They must follow all the main health benefits that Medicare offers. Plus they offer extra benefits that Medicare does not.

Answer: No, as long as you make your payment, they cannot cancel your supplement. The only remote possibility would be if they went out of business!

Answer: Absolutely you need to do something! You need to carefully read the ANOC (Annual Notice of Change) that you will receive by the end of September. Further, if any of your Rx's are brand names, you need to check their Rx formulary after Oct 1st, when it will be available online. Then decide, depending on any changes, if you want to change your plan.

Answer: Original Medicare covers all specialists who accept Medicare, including ophthalmologists. But optometrists are not covered by original Medicare. However, Advantage plans cover both types and usually offer an eyewear allowance.

Answer: That depends on the medication. But first of all, you didn't say whether your current plan covers that new Rx? Is it a brand name or generic? In either case, you can check the 2026 formulary of your plan, when it is available after Oct 1st, to see if it's in the formulary.

Answer: No, you cannot see any providers out-of-network. The exception to that is any urgent care and the ER of any hospital in the US. Your agent would have explained to you that with an HMO, other than those 2 examples, you cannot go out-of-network. If you do, you would pay full charge and the Dr does not have to follow Medicare allowable charges.

Answer: CMS does not allow "clever marketing." Everything that an Advantage plan publishes must be approved by Medicare (CMS). Depending what county and state you live in, some Advantage plans have a small premium and some have none. All plans have co-pays, and sometimes co-insurance (Part B Rx's and DME). Some also give-back money/month as an offset to your Part B premium. Do your research with a qualified Medicare agent!

Answer: Yes, the 5-Star Special Enrollment Period is different than the AEP and OEP. If an Advantage Plan or Part D plan (though I've never seen a Part D plan awarded 5 stars!), has been awarded 5 Stars, you can enroll anytime during the year, from Dec 8 of the current year, until Nov 30 of the following year. Obviously, you must live in the service area of the plan.

Answer: First of all, you need to be in a valid enrollment period, in order to make a change from an Advantage plan to original Medicare, and that only happens during the Annual Enrollment Period, Oct 15 to Dec 7, and then again during the Open Enrollment Period from Jan 1 to Mar 31. Secondly, with a supplement, you would have health underwriting in most states, and with a serious illness, you would be turned down.

Answer: Max out of pocket means exactly what it says. It's the total you paid for all health services in either co-pays or co-insurance, on your plan, year to date. Rx costs are excluded from that because the Rx MOOP is $2,000. So if you reach your MOOP of health costs, then yes, you will not have any further co-pays or co-insurance, again, excluding Rx's.

Answer: I assume your question is related to the LEP (Late Enrollment Penalty) for a Medicare Part D, drug plan. For those who don't know what that is, if after turning 65, you decide to stay on your employer health insurance, and you are able to do so because there are 20 or more employees on the group health insurance. And during that time, you only have Medicare Part A, which you get when you turn 65. But when you decide to leave your employer group health insurance and sign up for Medicare Part B, and then either join an Advantage plan which has Part D coverage, or buy a supplement + Part D plan, Medicare will send you a letter asking you to provide information about the drug coverage on your previous group health insurance. If you don't, or can't provide that info, you will pay an LEP every month for the time that you could not prove that you had a Rx coverage from when you turned 65. It amounts to close to $5 per month, for every year you did not have Rx coverage. So for example, if you stayed on your group health plan til age 70, and did not save your health card to prove your coverage, you will pay about $25 per month to Social Security, for the rest of your life!!! Moral of the story, don't throw away your prior employer health card!

Answer: First of all, it's a scam if you receive a call from any agent, other than your agent, attempting to talk with you about Advantage plans. According to CMS (Medicare) such a call is 100% illegal! Just hang up on such calls. Second, Medicare will never call you asking for your Medicare number. If Medicare wants to communicate, it will be by mail. Third, NEVER return those postcards claiming to come from Medicare, wanting to inform you about "updates" to your plan. There CANNOT be any updates or changes to your plan during the year! Returning such a postcard gives that agency (not Medicare, if you look at the return address!) permission to call you. Call your agent if you have any questions about a suspicious call.

Answer: That's a complex question to answer. Medicare covers the basic lens for free. Basic means that it corrects for near-sightedness. But it does not correct for astigmatism. So the basic lens itself is free, but the procedure costs. It's considered as out-patient surgery at an ambulatory center. Advantage plans have co-pays for that. So the issue is, the cost of a lens that in addition, corrects for astigmatism, is very expensive. Question is, how much astigmatism do you have that would, or would not require that lens? Or, are you willing to wear glasses after cataract surgery? That's not question I want to answer here. That's a question for your optometrist (not your ophthalmologist!).

Answer: Yes of course you will! Every Advantage plan and stand-alone Part D plan is required to send an ANOC every year in late September. It's very important to go over the ANOC.

Answer: Firstly, it is 100% illegal, according to CMS, for a Medicare Agent (aka a licensed health insurance agent) to "cold call" anyone and pitch a Medicare Advantage plan, without giving prior permission for the call, either in writing (returning a post card), or verbal. As for the "free groceries" that's only available to someone who has both Medicare and Medicaid, and enrolling in a Dual Medicare Advantage plan. I tell my clients who receive such calls to get the name of the agent and report him/her to both CMS and the company they represent. They will lose their contract!

Answer: It's important because previously that MOOP was $8,000! But if you are only taking generic Rx's, tiers 1 and 2, those are typically low co-pays of $1 to 5. So the $2,000 MOOP is irrelevant. But if you are taking Rx's that are tiers 3, or even 4 or 5, that MOOP is great!

Answer: Wow, the financial risk is enormous! Do the math. What do you think the Medicare allowable charge would be for a hospital stay, including possible surgery? The cost likely starts at $50K and rises to maybe $100K or more. Now do the math, what's 20% of that $$? That's your risk.

Answer: If you are asking about an Rx that you purchase at a pharmacy, that's covered by your Part D plan, not Medicare. You need to call your Part D plan to ask your question. But if you are asking about an Rx that is administered at a doctor's office, typically an infusion of some kind, that is covered by Part B of Medicare, so you would call CMS (tel# is on the back of your Medicare card). And lastly, if you are on an Advantage plan, you need to call you plan to ask about the coverage.

Answer: Actually more people are enrolling in Advantage plans each year! I don't know where this question is coming from, unless it comes from reading news on Facebook!

Answer: There is no relationship between health insurance (Medicare) and life insurance. The need for life insurance is based on the potential financial needs in the case of death of one of the spouses, i.e. mortgage of the house, life style, etc.

Answer: The disadvantages of an Advantage PPO are the high co-pays, as compared to the HMO's. Also, the extra benefits - dental, vision, hearing, etc - are much less as compared to HMO's. The only advantage, as compared to an HMO is that you don't need a referral to see a specialist. But there are United Healthcare HMO-POS plans in varying areas that have the fairly low co-pays of an HMO, but don't need a referral for a specialist. See if one of these is in your area.

Answer: First, you need to sign up for Medicare Part B, assuming you did not do that when you turned 65, which you should not have. There are 2 forms from CMS (Medicare) that you need to use. Have your agent email them to you, and after your employer has completed the employment form, bring them both to a local Social Security office 2 months before your retirement month. Be sure to indicate in Box #12 of the personal form, which date you want Part B to start. Then speak with your Medicare agent to start the process of understanding whether you want to stay in original Medicare and buy a supplement insurance policy (Medigap), plus a Part D Rx plan, or choose an Advantage plan which includes an Rx plan. It's very important that you make that choice within 63 days of losing your employer group health, so you don't get an LEP (Late Enrollment Penalty for Part D), but moreover, that you are not without health insurance!

Answer: It is very rare to be able to reduce your IRMAA because most of the time, it's based on your taxable income from 2 years prior. The only exceptions are if the higher income was from a 1-time payout, typically a pension, or property sale. If your current income is dramatically lower that what it was 2 years ago, there's a form on SSA.gov to appeal it. Good luck!

Answer: You can find providers in 2 ways. First, find the online provider directory of your plan. Or, call your agent and have him/her email you an updated list.

Answer: I assume you chose to stay in Original Medicare, versus an Advantage plan for a reason? The extra benefits of Advantage plans are just that, extra, and not a reason to choose an Advantage plan. Are you aware that you would be in a Dr network with an Advantage plan? And if you chose a PPO plan, the co-pays would be quite high, compared to an HMO. In my opinion, unless you can no longer afford your Medicare supplement, get yourself a dental plan. Ask you dentist what they recommend. They are not expensive.

Answer: If you are receiving SSDI benefits, you will be auto enrolled in Medicare Parts A & B, two years to the month, when you received your first SSDI check. There is nothing further to do.

Answer: You are mistaken. Advantage plans do not offer incentives to enroll, that is forbidden by CMS. However, agents can offer incentives, but those are also strictly controlled by CMS. Gift cards that can be readily converted to cash are forbidden. Any incentive over $15 is also forbidden. So nothing is suspicious.

Answer: All Advantage plans must follow original Medicare in all the coverages. Hence all Advantage plans will cover occupational therapy. However the co-pays of plans will be different.

Answer: Yes, you are given an SEP to enroll in another plan. But you might have a 1 month gap of returning to original Medicare, which would not be good, since you would not have a supplement to cover the 20% that Medicare does not cover. Moral of the story is to return that Chronic Verification Form before the 60 days is up!

Answer: I will answer that question first with a question. Would you buy a home, or sell your home, without either using a realtor or a lawyer to do the docs? I doubt it. So why try to figure out the complexity of Medicare plans and the various companies, on your own. Us health insurance agents who specialize in Medicare plans must do a series of re-certifications and trainings every summer. To us, this is not complex, but to the general public, it is. It doesn't cost you anything to use an insurance agent, so why not? Just be sure to use an independent agent, not a captive agent to one company. We make the same commission from all plans, so we won't steer you to one plan over another.

Answer: That depends on what coverage you have. A supplement is valid in all 50 states and US territories. An Advantage plan will need to be changed to one at your new location. Or you can return to Original Medicare and buy a supplement. Due to the move, you will have a guarantee issue for the supplement, but the price will be based on your age.

Answer: I assume you are asking about an Advantage plan because dental is not covered under original Medicare. The best way to find a dentist who is in our Advantage plan network is to ask your agent, who signed you up for the plan, to send you a list of names! That's why you need an agent. Alternatively, you can look that up in their provider portal... good luck.

Answer: The fact that you paid into Medicare for years has nothing to do with a supplement turning you down for health issues. But it sounds like you waited past your guarantee issue to apply for a supplement. Guaranteed issue is either when you turn 65 and for 5 more months, or when you drop employer group health coverage and sign up for Part B. There are a few other guarantee issue periods outside of that, like having an Advantage plan and moving from their service area. But if you did not qualify under those conditions, you are subject to health underwriting in most states. Moral of the story - do your homework before it's too late.

Answer: I am glad someone asked this question because it's very important to select the best Medicare supplement the first time and not try to change going forward. Why? For 2 reasons: #1 if you change to another company after a few years, you will pay a higher price because your age is higher, and #2 You will be subject to health underwriting after the first 6 months, so if you have any serious health issues, you won't be able to change. So then the question is, "How can I choose the best supplement the first time?" Answer is: #1 compare the rate increases of each company over a 10 year period, especially the last 4 years. #2 Don't choose a company that has created a group supplement, because the group could be dropped in the future and your rate will jump! #3 Choose the least expensive supplement, i.e. HDG or N. #4 Find an experienced Medicare agent who represents multiple companies.

Answer: That's a difficult question to answer because a lot depends on where you live, what's the cost of supplement plans, what are the co-pays of Advantage plans in your area, and what is the Dr network for those plans. So you really need to sit down with a licensed, local health care agent who specializes in Medicare plans. Anyone else attempting to answer this question in a general way, just can't.

Answer: Yes! A bone density test is one of many listed preventative care tests covered by Medicare. Do it! I do suggest you get a list from your PCP as to that list of annual, or bi-annual, covered tests.

Answer: It appears that whomever the agent was, who signed you for the N plan, did not properly explain it to you. The N plan covers everything after you pay the Part B deductible ($257 this year), plus you sometimes will pay up to a $20 co-pay for some provider visits. So yes, the N plan will cover the MRI.

Answer: I suggest that you do the math. Look at the total cost of your Dr visits, plus the monthly cost of the plan, and compare that to a plan with a higher premium, i.e. the G or N plan. And think about it not for just 1 year, but 10 years. You will likely find the savings to be substantial for the lower premium plan.

Answer: I believe the HDG plan offers the best value. HDG stands for High Deductible G plan. The deducible is not high, it's $2,870 this year, and Congress controls that number, not any company that sells the HDG plan. It's a catastrophic plan that only pays out when that deductible is met, which can only happen with an in-patient hospital stay. I look at insurance over long time periods, 10 years, 20 years. And during that time frame, it would be virtually impossible to be hospitalized every year! So during that time frame, the client would save a huge amount of money, compared to buying a full G plan. There's one company that sells the HDG at the best rate. Consult your insurance agent, but they will be reluctant to sell you that plan because their commission is very low. Insist!

Answer: Original Medicare does not cover hearing aids. Most Advantage plans do offer some kind of allowance or co-pay for various levels of hearing aids. Some plans also cover the more recent and less expensive OTC hearing aids. Check you Advantage plan for details.

Answer: There are 2 major misconceptions that my clients fall prey to: #1 are scam calls claiming there are updates to their Medicare plans. Of course nothing can change mid-year. #2 scam calls claiming they qualify for a food card. That's only possible when a client has both Medicare and Medicaid, which is rare, since the qualifying income and assets are very low. In both cases of #'s 1 and 2, the real purpose of the caller is to convince the client to change to another plan, so that agent can get commission. What client's don't even realize is the fact that the call itself is 100% illegal to begin with! So why would a client want to have an agent who conducts business illegally?!

Answer: Medicare does not typically cover emergency health costs outside the US. But most Medicare Supplements do cover up to $25,000 of foreign travel emergency. And Advantage plans do the same. You would need to pay the bill, and then get reimbursed back to the co-pays of your Advantage plan, or deductible of your supplement. However, I advise my clients to take the health insurance of the cruise! It's not expensive and it covers costs that would not be covered by your supplement or Advantage plan, such as emergency evacuation. Be sure the cruise health coverage is primary and not secondary! Enjoy your cruise!

Answer: The only bill you will have is the Medicare Part B deductible. This year, 2025, it's $257, unless you have already met the deductible this year.

Answer: What changes are you referring to? No changes to original Medicare have occurred in 2025. And Advantage plans cannot change mid-year. When you receive your Annual Notice of change in late Sept, you can then see if there are co-pay changes to your plan for 2026. If you consider a change, remember 2 things: #1 all Medicare Advantage plans follow original Medicare for the core health benefits, and #2 be sure your Dr's accept any plan switch you may consider. Most people do not change plans from one year to the next.

Answer: Well that's easy to answer, no more donut hole! The max you can pay for Rx's in 2025 is $2,000, not matter the retail cost of the Rx, or the Rx deductible of your plan. Both figures go towards the $2,000.

Answer: Some people consider the following to be disadvantages of an HMO Medicare Advantage plan, however, I do not. #1 need referrals to see most specialists. #2 Can only see Dr's in the HMO network. #3 Cannot see Dr's outside of the county or counties of the HMO plan. However, the Advantages are: #1 low co-pays. #2 during travel in the US, can get care at any urgent care, or the ER of any hospital, on the co-pays of your plan. #3 typically better ancillary benefits, i.e. dental, vision and OTC. #4 better health outcomes because your PCP is monitoring all your specialist visits and Rx's. I believe the advantages of an HMO outweigh the disadvantages, especially better health.

Answer: That depends what Medicare coverage you have. If you have a Medicare supplement, likely you will not need to change. Best to contact the company and ask. But if you have a Medicare Advantage plan, then definitely yes, you need to change plans! And you have a limited time to do so: the month you moved, and the 2 following months.

Answer: No, your income has nothing to do with your Medicare eligibility. But your income will effect your monthly Part B premium, if it's over a certain amount.

Answer: You have insurance coverage. It's called Medicare. What you don't have is coverage for the 20% that Medicare doesn't pay. That SSI changed to SS is not relevant to this issue, unless the total gross monthly income for you and your spouse, qualifies for Medicaid in your state. Otherwise, you have 2 choices to cover the 20%. You can see if you qualify for a Medicare supplement, based on your health, and ability to pay the monthly premium. Or you can wait til the annual Enrollment, which starts on Oct 15th and sign up for a Medicare Advantage plan. None have health underwriting, and most have a $0 monthly premium and a built-in Rx plan. But since you have gone over 63 days without an Rx plan, you will pay the LEP (late enrollment penalty) on a monthly basis, for the rest of your life.

Answer: No, Medicare cannot drop you for health reasons! Nor can an Advantage plan drop you for health reasons! Nor can a Medicare Supplement drop you for health reasons. Nor can an under-65 plan on the Affordable Care Act drop you for health reasons! Enough said!

Answer: Simple answer. Would you prefer calling customer service of either your Advantage plan, or Supplement, then pressing various numbers, getting put on hold, and passed around? Or would you prefer to speak with your LOCAL agent? Of course, you need a local agent who answers the phone.

Answer: Medicare generally does not cover foreign Medical services. But some Medicare supplements will partially cover that, as well as Advantage plans will cover up to $25K. But they will not directly pay the bills of a foreign hospital, you will. But upon your return, you can submit the bills (in English) and with their medical codes highly itemized to get partially reimbursed by either your Supplement or Advantage plan.

Answer: No! Medicare Part A does not cover most of what happens to you in the hospital - tests, surgery, Rx's, and care from medical professionals in the hospital. Those are all covered by Medicare Part B.

Answer: If you are drowning in bills, it sounds like you did not enroll in a Medicare supplement policy. Remember, Medicare pays 80% and you are responsible for the 20%, after you have paid the Part B deductible, which is $257 in 2025. If are are still within 6 months of your Part B enrollment date, you can sign up for a Medicare supplement policy and still be in a guaranteed issue timeframe, meaning you are not subject to health questions (most states). If you are past your Part B date, you still may qualify to enroll in a supplement. You need to speak with a qualified and experienced health insurance agent who focuses on Medicare and is local to you.

Answer: This is a question I often get and has a common misconception that with either Original Medicare, or a PPO Advantage plan, a client can see any Dr, anytime within the US. Why is this not likely? Because unless the client has a prior relationship with that Dr, and has their medical records with that Dr, it's very unlikely to be able to get an appointment. And even if both of those are true, getting same day appointments these days is also rather unlikely. So with any Advantage plan, either PPO, or HMO, a client has the ability to go to ANY urgent care, or the ER of ANY hospital in the US, on the co-pays of their plan. Also, for foreign travel, all Advantage plans have $25,000 for foreign travel emergency. The client would need to pay the foreign hospital, and then get reimbursed from their plan, back to the co-pays of their plan. So just being a frequent traveler is not necessarily a reason to choose original Medicare over an Advantage plan.

Answer: In my opinion, not just as a Medicare agent, but from my experience as a 76 y.o. with an HMO, my quality of care depends on my Dr's, not the plan. Also, I sometimes get calls from clients blaming the plan for something that did not go well for them. But when I listen to what happened, the problem was always with their Dr, the hospital, or staff, never the plan!

Answer: Yes for sure it will help! In 2025 the "donut hole" is gone, so your max Rx cost is $2,000 for all Rx's that you take

Answer: Yes, supplements are increasing in price now more than in the past, due to higher utilization due to covid. As for matching a hospital indemnity plan with an Advantage plan, that depends on the hospital co-pay of the Advantage plan. If it's a high co-pay, that might be a good idea, depending on the cost of the indemnity plan. Bear in mind, hospital stays are rare, so do the math with the indemnity plan cost compared to a hospital stay over say, a 10 year time period, to see if it makes sense.

Answer: Clearly the agent who signed you up for the PPO, didn't explain the out-of-net ramifications! The point of having a PPO is not to go out-of-net, but #1 to be sure that most, if not all your Dr's, accept the plan, and #2 not needing referrals to specialists. Personally, I prefer an HMO, much lower co-pays and you still have emergency services across the US - any urgent care and the ER of any hospital.

Answer: Medicare supplements are controlled by Congress, so the coverages are the same across the US, but the premiums vary from state to state and county to county. Medicare Advantage plans all have the same requirements - live in the county or counties of service. There is no health underwriting for Advantage plans.

Answer: Good question! A few things. #1 don't call any ads on the TV! #2 Don't reply to postcards claiming to come from Medicare and wanting to update your benefits. If you look at the return address of these postcards, it's an insurance agency, NOT Medicare. By signing and returning these postcards, you've given written permission to be contacted by an insurance agent who is not local to you and not knowledgeable about your area. Don't do it! #3 Don't take any phone calls from telemarketing companies or even individual agents. Those calls promoting Medicare Part C, aka Advantage plans, are 100% illegal without your permission giving them to call you! Why would you do such important business about your healthcare to someone who called you illegally?! #4 Don't click on any text messages, or email links, about Medicare. They will likely put a virus on your device to steal your info! #5 As always, if some ad sounds too good to be true, it is too good to be true! Always call your trusted agent.

Answer: Sorry, but that's not an equivalent question. Medicare Part D only covers Rx costs. You would still need to buy a supplement policy to cover the 20% that Medicare does not cover. Medicare Advantage is an all-in-one plan that covers both Rx's and the other costs of healthcare, (following the health coverage of original Medicare), typically with co-pays and sometimes co-insurance, and in some cases, without a monthly premium. But Advantage plans have Dr networks. Best to sit down face-to-face with a good insurance agent and do a needs analysis.

Answer: In years prior to 2025, someone would choose a high cost Part D plan in order to have low Rx co-pays, especially for brand Rx's. But now, with the donut hole gone, and the $2,000 cap on annual Rx costs, it makes much better sense to choose a lower cost Rx plan because once the $2,000 is met, you would not want to continue to pay a high premium for the Part D plan, for the balance of the year.

Answer: If you took out your G supplement in your guaranteed issue period, i.e. 6 months within the start of your Part B, then yes, you are fully covered. But if you took out the policy outside of your guaranteed issue period and did not inform them of the pending knee replacement, and they did not find it in your medical records, then no, you would not be covered.

Answer: If you are on an employer sponsored plan, either a supplement to original Medicare, or an Advantage plan, that question needs to be posed to the insurance sponsor. Usually, plans are individual to each spouse. But it needs to be confirmed if the spouse of the other spouse who initiated that plan, can keep the plan after that spouses death. Not a simple answer.

Answer: Yes, CMS looks back 2 years each year at your income, and will adjust or remove your IRMAA accordingly. The only time that you could request an IRMAA adjustment would be if it was a 1-time income increase to do with a pension payout, sale of a home, or something not related to ordinary income. There's an online form for that purpose.

Answer: Your Medicare agent should be informing you of these changes to Advantage plans. He is permitted to do son on or after Oct 1st of each year. As for Medicare supplement policies, depending on which plan you are on, the only changes could be the Part B deductible and the High deductible amount for those on the HDF or HDG plans. Congress controls those numbers, not the plan. Supplement premium increases can happen anytime during the year.

Answer: Medicare covers robotic knee replacement. It would be the same co-insurance or co-pays as regular knee replacement surgery.

Answer: That's not a question that can be answered in a generalized, fit-all reply. Many factors determine which is more suited: #1 Do you live in a county that has a large number of Dr's who take multiple plans, or is it a rural county with few providers? #2 Do all your Dr's take the same plan? #3 Can you afford a supplement for the long-term, if you so choose? (And supplement premiums will rise in time.) #4 Are you ok having to change Dr's if suddenly one of yours no longer takes any Advantage plans? (rare, but can happen) A qualified and experienced LOCAL health insurance agent who knows the Advantage plans in your area, is best qualified to determine which is best for you. Stay away from call-centers, and ignore generalized articles you find online, that are "click-bait."

Answer: It works exactly as you are stating. Your Advantage plan has a $350 co-pay for each day you are hospitalized, up to 7 days. If you are in-patient longer than 7 days, there is no charge. When you have an Advantage plan, the hospital deductible is not in effect, only your daily co-pay.

Answer: You are using the word "covered" as if that equals "free." First, you are not indicating if you are on original Medicare with a supplement, or an Advantage plan. Either way, an ambulance is not free! You either have co-insurance with original Medicare, (or the supplement would cover that, depending on the letter of the supplement), or a co-pay with an Advantage plan. Covered does not mean free!

Answer: My response would be, did you enroll using a telemarking agent? Or did you enroll in person with a licensed and experienced health insurance agent who specializes in Medicare plans? Either way, they are required by law to go through the full summary of benefits of the plan. My point is, you always want to do an in-person enrollment with an agent, where you are given the booklet of the plan and can thoroughly go through all the benefit details. At this point, you can lodge a complaint against the agent with both the plan and CMS (Medicare).

Answer: That you paid into Medicare for years has no relation to either the co-insurance (20%) on original Medicare, or the co-pay on an Advantage plan, that you pay for specialist visits. Those costs don't just decrease according to you paying for Medicare!

Answer: That's an easy one. Call CMS (Medicare) and ask for a new card to be sent. A tip to get through their menu system - press the * and # keys on your phone, successively 6x. The auto system will give up and get you an agent.

Answer: There is no nursing home coverage under Medicare, and therefore also under Advantage plans. So there is no effect by auditing because it's simply not covered.

Answer: There is no "donut hole" in 2025. And we are in 2025, so there is no "before." Your Rx cap is $2,000.

Answer: The most common misconception my clients have about Medicare is that it covers long-term care. It does not. And if a person does not have a long-term care plan by age 65, and wants to get one, the cost is prohibitive!

Answer: Yes, you can "try" to change your Medigap plan anytime during the year. Medigap policies are not subject to the change rules of Advantage plans - AEP and OEP. BUT... 2 issues will arise - #1 if you switch companies, you will be subject to health underwriting (in most states), and #2 your premium will increase because now you are buying a supplement at an older age. Bottom line I tell my clients who want a supplement - this plan is for life, unless a time comes that you can no longer afford it and want to change to an Advantage plan.

Answer: If you are taking generic Rx's, typically they have a $0 to $5 co-pay, so you can't save more. But sometimes your plan places a generic Rx in a higher tier, i.e. 3, in which case either your pharmacy will give you their cash discount, or you can use a GoodRx coupon. Nowadays, pharmacies are required by law to automatically offer you the lowest price - either your Rx plan, their cash discount, or GoodRx.

Answer: Medicare (and the Advantage plans) basically cover unlimited P/T. But, you need to meet 2 criteria to continue to get an authorization for P/T. #1 Medical necessity, and #2 ability to improve (i.e. range of motion). As long as those 2 criteria are met, your doctor can write a script for continued P/T. But once one of those criteria are not met, i.e. there still might be medical necessity, but no further ability to improve, P/T is done.

Answer: That's old news! It was part of the IRA (Inflation Reduction Act) last year, under the Biden admin. It means that you will only pay whatever co-pays your Rx's cost you during the year. And you can never pay more that a total of $2,000/yr for all your Rx's. So for example, in 2024, say you were taking Ozempic with a $47 co-pay on your plan, but once you hit the donut hole of $5,080 total retail cost of Ozempic, which happened fast because it's retail cost was $1,250, you then had to pay 25% of the retail cost of Ozempic for the balance of the year! That's no more. But if you don't take any brand name Rx's you never hit the donut hole anyway.

Answer: First, find a licensed health insurance agent local to you (not from a call center) who is an independent agent, representing all the major plans in your area. Second, be sure this agent has years of experience with Medicare plans. Third, be sure this agent will meet you in person to discuss your options. Sorry, one piece of advice in 2 sentences doesn't work!

Answer: CMS already has very strict regulations on Medicare Advantage marketing and sales practices. The problem is, there are call centers that don't follow those rules and illegally call Advantage plan members without prior permission and push them to change their plan without doing all the due diligence with the client. Clearly the plans are not terminating their contracts with call centers who do this illegal practice!

Answer: All Advantage plans give you coverage anywhere in the US when you are away from your network area - any urgent care facility, and the ER of any hospital. And if you go to the ER and are admitted, the ER co-pay is waived and the hospital co-pays starts. And it's the co-pays of your plan. What you don't have on an HMO is the ability to see a doctor outside your service area. You did not specify if you have an HMO or PPO. If you have a PPO, you can see a doctor who accepts your plan, anywhere in the US, however, if you don't already have a relationship with them, and have not transferred your medical records, they will not see you. You can also go out-of-network on a PPO, but you may have to pay the full charge and get reimbursed from your plan back to your out-of-network co-pay.

Answer: If you are on social security disability, you automatically are enrolled in Medicare, 2 years after starting to receive disability money from the SSA. But if you are on private disability insurance, you do not get Medicare.

Answer: Yes. You have an 8 month period to apply for Medicare Part B. But you only have a 2 month period after losing employer coverage to enroll in either a Medicare Advantage plan which includes Part D coverage, or a supplement to Medicare and a stand alone Part D plan. If you have a gap for more than 63 days from your loss of employer coverage, and enrolling in either of those, you will incur the LEP, known as the Part D late enrollment penalty. I tell my clients who are planning to retire, or drop employer coverage, to apply for Medicare Part B 2 months, before to avoid the LEP.

Answer: If you have a Medicare Advantage plan that's a PPO, then you do not need a referral to any specialist! But you may be confusing a referral with an authorization, which my clients often do. If you are seeing a doctor for any kind of procedure, which would include a dermatologist who may be removing a lesion that was previously identified as cancerous, that may require an authorization. And all plans, HMO, PPO and even original Medicare require authorizations. Further, if you have a Medicare Advantage HMO, you also don't need a referral for a routine dermatologist visit. But if you need a follow up visit after that, to remove something from your skin, that requires either a referral or an authorization.

Answer: With the loss of your husband, you are now filing a single tax return, not joint. If your income is above a certain bracket, you need to pay the IRMAA. The income bracket for a single filer is lower than the bracket for a joint, married filer, hence you are paying the IRMAA. The IRMAA is the increased Medicare Part B and Part D premiums you must pay when your income is higher than the basic bracket.

Answer: No, you do not. However, you can change whatever plan you are on. It becomes a second enrollment period for you. And at age 65, the cost of buying a Medicare supplement goes way down, if you choose that route.

Answer: That depends when you are wanting to enroll in a Medicare Supplement plan. If you are enrolling with 6 months of signing up for Part B, you cannot be turned down. Also, if you chose to take an Advantage plan when you signed up for Part B, you have a 1 year free look for the Advantage plan. If by the 11 & 1/2 month, you decide to switch to a Supplement, you also cannot be turned down. Also, if you chose an Advantage plan, then moved from the service area of your plan, you cannot be turned down. Outside of those criteria, you will be subject to medical underwriting, with a few states being an exception. Bear in mind, the Supplement premium will rise in the years after your 65th birthday. Speak with your licensed health insurance agent who is a Medicare expert in your area.

Answer: This is a common question for those still working and on employer group health insurance. The exact definition from CMS (Medicare) is: If you want to keep your employer group health insurance, and there are 20 or more employees ON THE PLAN (not just employed) then you can stay on that plan and will not be penalized later when you retire and enroll in Medicare Part B. However, you need to check if the SSA auto enrolled you in Part A, 3 months before your 65th birthday (that used to be automatic, but not so anymore). And you need to also check if your group health plan drug benefits meets the minimum required by CMS. If not, you will need to sign up for a Part D plan within 3 months after your birthday month, to avoid a future penalty (LEP).

Answer: Plans can change from year to year. You always need to check your Part D plan in the Annual Enrollment from Oct 15 to Dec 7, with Jan 1 as the effective date, if you make a change. That's the only time of year when you can make a change to your Part D plan, unless you move to a different state, or have some other SEP. Your agent, who signed you for your supplement, should check it for you. You can also call Medicare to do that, but during that time they are very busy. If you do it on your own, go to Medicare.gov, create an account, and check for plans.

Answer: First, there's no such thing as a "bad" Advantage plan. All Advantage plans, by law, cover what Medicare covers. The difference between Advantage plans are the Dr networks and co-pays, plus ancillary benefits, that's it. My clients trust me and don't ignore my advice! Those who respond to illegal calls from telemarketing agents, or call the TV ads, well, those are not my clients!

Answer: Yes, your gastroenterologist will determine the frequency of colonoscopies that will be required for you. Medicare will cover that with either co-insurance, or a co-pay, depending on whether you stay on original Medicare, or choose an Advantage plan. All Advantage plans, by law, cover what Medicare covers.

Answer: SNP's (Special Needs Plans) vary according to the county. There are 2 types:

1. D-SNP - Dual plans for those with both Medicare & Medicaid. The advantage of joining a dual plan is being in a large Dr network of that Advantage plan, rather than trying to find Dr's who accept both Medicare and Medicaid. Also most dual Advantage plans offer more benefits, i.e. a food spending card, dental, vision, etc.

2. C-SNP - Chronic plans for those typically with diabetes, heart disease and pulmonary illness, and sometimes kidney failure.

3. I-SNP - Institutional Special Needs Plans are for individuals who need a long-term stay in a medical institution, such as a skilled nursing facility or rehabilitation center.

SNP's can be joined any time during the year, if you are newly qualified for one.

Answer: United American, for the following reasons:

1. Lowest rate for the HDG, high deductible G plan, which in the long run, will save a lot of money!

2. Great customer service! You can reach a live person in the US!

3. Ability to create an online profile to see your claims.

4. At the 2-yr anniversary, gives you a 30-day window to change your plan within United American without health underwriting.

5. If you do change your plan within United American, your original issue age is kept.

Answer: Unless there is an SEP (Special Enrollment Period) in your area due to a disaster related issue that you qualify for, or you qualify for a chronic plan, or you have full Medicaid, you will have to wait until the Annual Enrollment Period, Oct 15 to Dec 7, to change your plan to next year's plan. Just remember that you can always change your PCP.

Answer: I always tell my clients to focus on the core benefits of the Advantage plan, in this order:

1. Are all your "must-have" Dr's on the plan?

2. What are the co-pays and max out-of-pocket

3. Does the plan have a monthly premium, if so how much?

The ancillary benefits of dental, vision, OTC allowance, etc., are of least importance, unless #'s 1, 2 and 3 are equal, then the other benefits can be compared.

Answer: This depends on their situation:

1. The rule from Medicare is that if 20 or more employees are enrolled in the group health plan of the employer, the senior can delay taking Medicare Part B without being later penalized. Notice I said 20 employees on the group health plan, not just 20 employees!

2. Compare Medicare premium to the group health premium and compare the co-pays and max out-of-pocket.

3. Does the senior have a younger wife on his group health plan, and if so, does she have an option on her employee plan, if she is still working.

Answer: Medicare does NOT cover long term care, i.e. nursing home care! Some Medicare Advantage plans offer some home health after an illness or surgery. But that is very limited. This is a common misconception that Medicare covers long term care. It does not.

Answer: It's much better and more advisable to work with a local agent! Why? Because he/she will have complete knowledge of the local plans. Also, a local agent will likely know many of the providers. Further, a remote/virtual agent will likely not be reachable during the year to help you with any questions, but a local agent will.

Answer: You are correct. And that was the job of the agent who changed your plan to check on each of your Dr's to see if they took your new plan. Did you use a prior agent who knew you? Or did you call a telephone number from a TV ad? Regardless, you cannot change your plan now. You must wait until the Annual Enrollment Period (AEP) from Oct 15 to Dec 7, to change your plan, with an effective date of Jan 1st, 2026.

Answer: Unable to answer a general question like that without knowing:

1. Do you have original Medicare with a supplement, if so what letter supplement? And do you have a Part D drug plan?

2. Or do you have a Medicare Advantage plan?

3. What Rx's are you taking?

Answer: That depends. You can under 3 circumstances - #1 You are within 1 year of starting an Advantage plan; #2 You moved from the area of service of your Advantage plan; #3 The Advantage plan was terminated by either CMS or the company. But if you are not moving out of the service area of the Advantage plan, you are subject to health underwriting in most states. Consult your Medicare agent for info related to your state.

Answer: First, there is no more coverage gap (aka the donut hole) in 2025. That was ended by the IRA (Inflation Reduction Act in 2024). Now, the max out-of-pocket on Part D plans, whether stand-alone, or part of an Advantage plan, is $2,000/year. All Rx's purchased through the plan go towards that max. Anything that might be purchased outside the US, or using GoodRx, or any other discount plan, does not.

Answer: I assume you mean cataract surgery? Medicare covers the basic lens, which corrects for distance. But that lens does not correct for astigmatism. An upgraded lens that does correct for astigmatism is rather expensive, about $2,500 to $3,000. I suggest you speak with your optometrist and ask if your level of astigmatism (cylinder) would require you to wear glasses after the cataract surgery, if you get the basic lens. If you just get the basic lens, your total co-pay for the surgery would be your co-pay on your plan for out-patient surgery, assuming they don't use a laser, but rather the micro-slit.

Answer: Your Rx costs cannot exceed $2,000 annually, according to the new Part D rules from the IRA (Inflation Reduction Act) from 2024. If that is still unaffordable, you can contact the manufacturer of the Rx on their website and find a form for reduction of cost, based on your income. You may also qualify for the LIS, based on your income (Low Income Subsidy). Call Medicare or the SSA to see if you may qualify.

Answer: First, do you have group health insurance through an employer that you might want to keep, either because your cost will be lower than Medicare Part B, or your wife is also on that plan and needs to stay on it? You can stay on that without future penalty from Medicare, if there are at least 20 employees on the group health plan. Second, if you do want to enroll in Medicare Part B, you can do that on SSA.gov during the time frame of your enrollment period - 3 months before your birthday month, the month of your birthday, and 3 months after, a total of 7 months. But you must also have an online SSA account, which is used to verify your identity, while making the online Part B enrollment. A good agent can talk you through all this.

Answer: The coverage gap, or "donut hole" is removed for 2026 and on. It's been replaced with a max out-of-pocket for the year, for all Part D Rx's of $2,000. That was accomplished in 2024 under Pres Biden's inflation reduction act, along with allowing Medicare to negotiate drug prices for brand name Rx's.

Answer: All Part D plans have a formulary which you can check to see if your Rx's are covered and at what Tier. Also, the max total cost for the year, starting this year, for all Part D meds is $2,000.

Answer: I have not come across that issue. Perhaps some hospitals in some counties are not taking some specific plans anymore for a planned surgery. But anyone on any Advantage plan can go to the ER of any hospital in the US and receive care, and be admitted, if needed, on their plan.

Answer: If you are already on Medicare, then you would already know that you are paying the IRMAA because Social Security billed you for that, or it's already coming out of your Social. It's based on your gross income, from a 2 year ago tax return. If you are not yet on Medicare, there are tables that will show the income levels and IRMAA. A good agent will have those to show you. The only way to dispute an IRMAA is if the higher income was due to a 1-time amount from a lump sum pension, or sale of a property. If you have vastly lower income now, you can also try. There's a form on SSA.gov to dispute it.

Answer: That depends. If your Rx's are all Tier 1 and 2 generics, they are already likely a $0 co-pay, or close to that. Also, some plans have a low co-pay for a Tier 3 brand name. The payment plan would be helpful if you are taking a brand name Rx, Tier 3, 4, or 5, with a high co-pay, and you plan also has a high deductible for a first time Rx order. In order to activate the payment plan, you would need to call your plan and ask them to do that. Don't ask a pharmacist to do that! Then your co-pay at the pharmacy would be $0, with the cost spread over the rest of the year, and billed to you from your plan, at no interest.

Answer: No, original Medicare has no dental benefits other than related to an illness or maybe an accident, but not implants in either case. Most Advantage plans do include dental benefits of varying degrees, but very, very few include implants.

Answer: You would need to check both what plans are available in that area, and the Dr network. You can check for plans on Medicare.gov, with a zip code. Also, if you moved from the network area of your plan, that would create an SEP (Special Enrollment Period) where, if you can't find a suitable Advantage plan, you could return to original Medicare and buy a Medicare Supplement in a guarantee issue. In a rural area, supplements would be less expensive and give you the full Medicare Dr network.

Answer: MOOP's on Medicare Advantage plans are the total of annual co-pays and co-insurance on the plan. Rx drug costs are excluded from the MOOP because they have a separate MOOP of $2,000/yr from the 2024 Inflation Reduction act. From my experience, it's very rare to reach the MOOP from just the co-pays. The rare exception from my clients have been those on chemo therapy infusions, because those are always 20% co-insurance of the Medicare allowable cost for the medication, which adds up.

Answer: The question is, where was that listing? If it was in a printed book that your plan sent you, that is notoriously inaccurate due to when it was printed! The best way to look up a Dr is on the plan's provider website, and then call the Dr to double check. But it is possible that during the year, a Dr can go off network. That was either done by the Dr or the plan, for reasons unknown to you and it is allowed.

Answer: HMO Advantage plans require Dr's to follow "metrics of care." They need staff to do that. But the outcome for a patient is much better! Actually, Dr's who are on "risk" Advantage plans make a lot of money, but they need to have a large client base on risk plans and the staff to support the documentation and referrals. A risk plan means the Dr is responsible to share the cost of care outside of his/her office, meaning specialist visits, ER, hospital, advanced imaging, etc. A practice that has a large Advantage plan client base can handle that and still make a lot of money.

Answer: An experienced Medicare broker should be asking you many questions on the phone, so he/she can prepare ahead of time which plan most suits you. Also, you want an independent agent who represents multiple Advantage plans in your county, 5 or more, and also supplements. Lastly, some who has at least 5 years experience and over 200 clients, or more. You can ask! Also, it's probably best to get a referral from friends, relatives or neighbors, of a broker they used and how often that broker communicates with them, either by phone, or email.

Answer: If you are on original Medicare with a supplement to Medicare, you can typically keep that supplement. Call the company to check. End of story. If you are on an Advantage Plan, you are given an SEP (Special Enrollment Period) of 3 months to change your plan to a plan in the state or county where you will move to: consisting of the month that you move + the following 2 months, to make the change. I always advise my clients who move out of state, to find a Dr in your new location from friends, relatives or neighbors, then ask that Dr for an independent agent who can advise on the local Advantage plans. Most Dr's know agents who they can refer the patients to. Until you make the change, if you need medical care, you can go to any urgent care, or the ER of any hospital. If you have a PPO Advantage plan, you can also see any Dr, either in or out of your network.

Answer: That depends. If you have an ACA plan (Affordable Care Act), then you must sign up for Medicare at age 65. But if you are on employer health insurance, the rule from Medicare is that you can keep your group health insurance, and not be penalized later for not taking Part B, if 20 or more employees are on the group plan. Not just employed, but on the group health plan. Second rule, does the drug plan of your group health meet Medicare's minimum requirements of Part D? If not, you will need to sign up for a Medicare Part D plan. Lastly, it's important to compare the cost of your group health plan, including the premium, deductible, co-pays and max out-of-pocket, to paying for Medicare Part B and either choosing an Advantage plan, or a supplement.

Answer: There is no "pat" answer to this questions. The variables are: #1 Where do you live, in a rural or urban area? Urban areas typically have more Dr's who take Advantage plans. #2 Did you or an agent, research your current Dr's to see which Advantage plans they accept? #3 Do you live in one place, or do you have a home in another state that you frequent? #4 Can you afford a Medicare supplement plan?

Answer: Simple answer... Plan F has no co-pays for any Medicare allowable service of any kind. An ER visit is Medicare allowable, assuming that the accident or illness could not have been handled by an urgent care.

Answer: That depends. If there is a similar generic medication for that illness, then Medicare can require "step-therapy" meaning the patient will need to try the generic to see if it works. If it does not work, or the patient exhibits a drug side effect to the generic, then the Dr can seek an authorization for the brand name. But if there are no other generic medications for that illness, then Medicare cannot deny the brand name.

Answer: Hospice comes under Medicare Part A, regardless of whether a person is on original Medicare, or an Advantage plan. In both cases, Hospice is free. It's typically offered when end-of-life is determined to be less than 6 months by the PCP. The service varies according to the needs of the person. Palliative care is not free, but follows the co-pays or co-insurance of their plan.

Answer: If you like to travel, especially outside the US, your question would be, "Do I have any coverage outside the US and how would it coordinate with my Medicare plan?"