Andrew Kramer, Medicare Insurance Agent

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?"

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

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: That's an easy one. Call CMS (Medicare) and ask for a new card to be sent: 800-633-4227. 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: 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: 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: 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: 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: 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: Medicare covers robotic knee replacement. It would be the same co-insurance or co-pays as regular knee replacement surgery.

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: 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.