Barbara Barnes, CMIP®, Medicare Insurance Agent

Answer: How much will it cost?

There is so much more to this question than just premiums. Of course, premiums are a part of it. Usually, Part A will be premium-free because you've already paid for it through payroll taxes, but there is a premium for Part B and Part D, and if you made more than a certain amount, the premium might be even higher than what most people pay.

Beyond Parts A and B of Medicare, you will need to choose how you want to receive those benefits. Do you want just Medicare A and B? Do you want to add a Medicare Supplement plan to Original Medicare for additional coverage? What about Prescription Drugs? Or do you want to forgo Original Medicare for a Medicare Advantage plan? Each option comes with different costs, risks and rewards. It's important to understand each option before you decide which is best for you. Then you still need to choose an insurance company!

Once you've decided on a plan and know what premiums you will pay, there are your deductibles, coinsurance, copayments and fees for the covered services you receive. Did you know that with Original Medicare, there is no out-of-pocket limit on how much your claims could cost? Usually, Medicare Advantage plans will have a maximum out-of-pocket amount, but that could be thousands of dollars. Medicare Supplements limit your out-of-pocket risk, but they often have higher premiums. Unless you have a low income and qualify for Medicaid, you will pay more than just the basic premiums for Medicare Parts A and B.

Confused yet? That certainly is not my goal, but I do want to convey to you that Medicare is complicated. This is why having an experienced Independent Insurance Agent who specializes in Medicare Insurance is so important.

Answer: You've heard that "there's no such thing as a free lunch." Well, the same is true of Medicare Advantage plans.

While it's true that there are Medicare Advantage plans that cost $0 in premium, they are not 'free' for a variety of reasons:

1. In order to qualify for a Medicare Advantage plan, you must have both Medicare Part A and Medicare Part B. There is a premium for Part B that must be paid every month.

2. You accept the terms and conditions of the Medicare Advantage plan that you choose, and that includes copayments and an out-of-pocket maximum for the services you receive. The fees you pay could add-up to thousands of dollars each year. While Medicare Advantage plans must be at least as good as Original Medicare, there will certainly be a cost to receiving medical care under Medicare Advantage.

3. Your Medicare Advantage plan is being paid by Medicare. Because they have taken-over responsibility for your medical needs, Medicare pays them a portion of what they expected to pay for your claims. The Medicare Advantage plan then decides how to spend that money in benefits. As the Medicare budget changes every year, so does the Medicare Advantage plan. It is important to review the changes in your Medicare Advantage plan every year.

4. You may end-up benefiting from Medicare Advantage by paying a little more for your medical claims, while receiving "extra" benefits like dental, vision, hearing, fitness, prescription drug and over-the-counter drug benefits at little to no cost. But in a year where you have a lot of expensive medical treatment, you could pay a lot more out of your pocket.

Answer: You are already running a bit behind. You may start the Medicare enrollment process as soon as 90-days prior to your eligibility. Medicare benefits may begin on the first day of the month that you turn 65 (yes - even before your 65th birthday). Medicare is not simple - there are many things that you need to think about before you head to the Social Security office or website to sign-up:

1. Do you need Medicare right away? If you have coverage through an employer, you might not need or even want to sign-up for Medicare right away when you turn 65. You might be able to wait until you retire.

2. Do you contribute to an HSA? If you do and you want to continue contributing to the HSA, you cannot have Medicare.

3. Do you work for a small employer? If your employer has fewer than 20 employees, you might need to sign up for Medicare right away, even if you plan to continue working, because for small employers, Medicare is Primary and the group health plan is Secondary.

4. If you work for a large employer with more than 20 employees, you may still want to consider which benefit is better for you - Medicare or your group health plan.

5. No matter how big your employer is, you may want to compare the benefits and premiums of Medicare vs your group health plan. It is possible that Medicare will offer beter benefits with less premium than your payroll contribution.

6. Consider your dependents. If your spouse is covered under your insurance plan at work and they are younger than you, you might want to keep your group plan so that they can keep their coverage.

There are many things to consider before signing-up for Medicare. This is why it's important to work with a Medicare Insurance Agent that you trust who will point you in the right direction. I prefer to meet with my clients when they are 64 1/2 to review all of these important details and formulate a basic plan long before they turn 65.

Answer: In my experience, the biggest mistake seniors make with Medicare is listening to their friends and choosing a plan based on what works well for someone who isn't in their shoes. Don't get me wrong - people who are already in the Medicare system can provide great insight into the things they like and dislike about their plans and experiences with Medicare, but they are not you. Only you know what is important to you. You know what your medical needs have been and what they are most likely to be in the future. You know how you feel about "managed care", prior authorizations and networks and only you know your budget.

Even if you listen to your friends and choose Medicare Advantage over Original Medicare, only you know what doctors you want to see and what medications you need to have covered on the formulary. And if your life experience is different and you already have a chronic condition, only you can decide if you would sleep better at night with Original Medicare and a Supplement plan than you would with Medicare Advantage.

When you choose your first Medicare plan, it could be the last health insurance plan that you choose for the rest of your life. This decision is too important to make on a whim or because a plan worked great for your pickle ball buddies. Give it the time and consideration that it deserves.

Answer: Maybe. It depends on WHY you choose to delay your enrollment.

If you delay your Medicare enrollment because your have coverage at work, possibly including a Health Savings Account that you contribute to for the tax benefits, you will likely be able to delay enrollment in Part A, Part B or both A and B, and then enroll for those benefits at a later date, when the employee benefits expire - usually due to retirement in some form. But don't delay when that coverage ends - you will have a limited amount of time to enroll without a penalty.

However, if you work for a small employer with fewer than 20 employees, you should not delay your Medicare benefits because your group health plan will be secondary to Medicare and you will need Medicare Parts A and B as your primary insurance, even if you continue with the group plan at work.

If you choose not to enroll for Medicare Parts A and B simply because you don't want it, or you don't think you need it, or you don't want to pay for it, then you will owe a penalty if you sign-up for it later, and you can only sign-up at a certain time of the year. That will be bad if you get a cancer diagnosis and then must wait another 10-months to get Medicare coverage.

Every situation is different, so it is important to consult with a Medicare professional to get answers to your questions and help you decide what option is best in your particular situation.

Answer: I enjoy helping my clients to make good decisions. It's as simple as that! I've worked in health insurance for 30-years and I've had the privilege of touching thousands of lives over that time. I love when I meet with a client and they reaffirm that they made the right decision for their needs, even if it was a different decision than their friends made. My job is to educate my clients so they can make the best decision possible based on what they need and want.

Answer: This is a trick question.

Neither option is better in every situation or for every client. They both have an important place in our healthcare payor system. It is important for each person to understand both options so that they can choose which is best for themselves. Beware of insurance agents who approach clients with a one-size-fits-all mentality on either side of this argument.

The best decision is one that is measured and educated and based on the individual needs, wants and priorities of the client.

Answer: Technically, yes. Medicare Supplement plans are not locked-in to an annual cycle like Medicare Advantage and Medicare Part D plans. This means that you can make changes to them at any time of the year.

BUT outside of the Initial Enrollment Period (when you're new to Medicare Part B), or a Special Enrollment Period, you will need to qualify through Medical Underwriting to make a change in Medicare Supplement insurance plans or companies. If you've recently been in the hospital, have medical tests or treatment pending or you have a chronic condition or use a lot of medications, you can be denied coverage. This is why it's important that you never cancel one policy without first having the new policy that you're replacing it with in place. Many clients have questioned this because the Affordable Care Act eliminated pre-existing conditions and made it so that people with pre-existing conditions could get insurance, but that law does not specifically apply to Medicare programs. It is possible that this could change in the future, but for now, Supplement plans are still medically underwritten and can be denied.

Answer: Maybe. It depends on what you've already done.

If you already chose your Medicare plans in lieu of a group plan at work, then you may be set and ready to roll. But if you delayed your full Medicare enrollment because you had coverage at work, you will need to enroll in Medicare Parts A and B before you may choose any other plan options, like Medicare Advantage or Medicare Supplement. It would also be a good idea to review any notices that you've received from your group plan to know where that plan stands in comparison to Medicare Part D and to see if you may owe a late enrollment penalty if the group plan was not as good as Medicare Part D.

Answer: Maybe. How long did you have a Medicare Advantage plan?

If you are still in your first year of Medicare Advantage coverage and you previously had a Medicare Supplement plan that you dropped to join the Medicare Advantage plan, you may exercise your 'Trial Right' Special Enrollment Period to return to your Medicare Supplement plan with no medical questions. If that plan is no longer available, you may choose another Medicare Supplement insurance company and enroll without Medical Underwriting, within certain guidelines.

If you enrolled directly into a Medicare Advantage plan during your Initial Enrollment Period and are leaving that plan within the first 12-months of coverage, you may also choose to return to Original Medicare and enroll with a Medicare Supplement plan without Medical Underwriting, again, subject to certain guidelines.

This process can be a bit tricky because you must first drop the Medicare Advantage plan and return to Original Medicare before you may enroll for a Medicare Supplement plan, and this can take some time. The Annual Enrollment Period is from October 15 - December 7 each year, and it is a very busy time of year for Social Security and Medicare, as most Medicare beneficiaries need to review and make changes to their plans during that time of year. It is possible that you could leave your Medicare Advantage plan and go back to Original Medicare only to have your Special Enrollment denied by the insurance company and find yourself without a Supplement plan while also outside of the Annual Enrollment Period, so also unable to re-enroll in your Medicare Advantage plan. If you want to do this, be prepared to start the process in October to allow enough time for the disenrollment and re-enrollment. You do not want to wait until the end of November or beginning of December to start this process.

Answer: You might save money at the dentist, if they accept your plan, but end up spending more on your medical needs.

Medicare Advantage plans have copays for most medical services. With Original Medicare you are responsible for 20% of Medicare Assignment after deductible, so if Medicare allows $72 for an office visit, 20% of that would be $14.40, but a Medicare Advantage plan may charge a flat $20 for an office visit copay. Also, Original Medicare allows you to see any doctor that accepts Medicare, while most Medicare Advantage plans require that you see only doctors that participate in their network.

Before you make this change, make sure you understand all of the provisions of the Medicare Advantage plan, and check to be sure the dentist and doctors you want to see will all accept the plan.

Answer: No. Medicare will cover medically-necessary health services, but that will not include dental, vision, hearing and prescription drugs that may be covered by your plan at work. Medicare is a very different form of health coverage than employer-provided group plans. Before moving into a Medicare plan, you need to understand the various parts of Medicare and the difference between Original Medicare and Medicare Advantage.

Answer: Yes. I do. But I hope that does not happen in my lifetime.

When I, started my career almost 30 years ago,Medicare was the lesser option. Employees who were leaving their group insurance programs were often disappointed by the coverage provided under Medicare. Almost 30 years later, that has changed. Most of the clients I meet with are pleased to see the lower deductibles and lower risk associated with original Medicare and a Medicare supplement. Especially for those individuals who have chronic conditions, original Medicare with a supplement limits their risk to less than $300 per year and allows them to go to the doctor without worrying about how much it’s going to cost. The problem is that someone is still paying the bill, and that someone is the US government through Medicare. Perhaps if the Medicare program had not been cannibalized over the years to pay for other projects, we would not be in this position. At this point, however, given the increase in healthcare inflation, and overall healthcare expenses, privatizing Medicare, and shifting the risk from the US government to private health. Insurance companies is looking more and more attractive to the US government. This shift, however, does not only shift the cost of healthcare from the US government to private health insurance companies, but also chefs that cost over to the patients receiving care, with copayments for every service they receive.

Answer: You should decide for yourself because only you know what your priorities are.

There is no single right answer for which is best between Meficare Supplement and Medicare Advantage. Both work well in their specific ways.

Medicare Supplements use Original Medicare as the base for coverage and Original Medicare allows you to see any provider in the country that accepts Medicare. Medicare Supplement plans generally have less managed care, so they are also easier to use when your doctor wants you to receive treatment ents or to have tests done. Generally, the premium is higher for a Medicare Supplement, but the claims cost is lower. But Supplements do not include ’extra’ benefits like dental, vision or hearing benefits.

Medicare Advantage plans usually require that you see a network provider to receive the higher benefit amount. Some plans will only pay when you see providers who are in network. Advantage plans are also known for managing care to save money, so your doctor will need to have most tests and treatments approved before they take place. You will have a copayment for every service you receive in an Advantage plan, up to a plan-specific out-of-pocket maximum. Generally, premiums are lower (maybe even $0) for Medicare Advantage plans, but claims are higher. Most Medicare Advantage plans do include ‘extra’ benefits, but those benefits vary by plan year and insurance company.

In summary, it is important that you understand all of your options before you make a decision. You should consult with a local Medicare insurance agent before you make a final choice. Your family and friends mean well, but they cannot advise you as well as a licensed insurance agent on this issue.

Answer: Eye health is important. Many medical conditions can be found through a comprehensive eye exam. So how much is that worth?

Medicare usually covers the part of your eye exam that looks for medical eye problems like cataracts, retinopathy, macular degeneration or glaucoma. Medicare does not pay for the vision refraction part of the exam for glasses or contact lenses. If you need treatment for a medical condition of the eye, Medicare will pay for that, too, but they usually do not pay for glasses or contact lenses.

Answer: Medicare pays for Medical visits with primary care doctors and specialists, as long as they’re medically necessary.

Answer: That is a full 1+ hour discussion. Reach out and I’m happy to discuss it with you. For now, please know that they are real and they work well for some people, but you do take more medical risk with them for a variety of reasons.

Answer: I absolutely hate the ad from Joe Namath saying that you can get money back for moving to Medicare advantage. While it is technically true, it is so misleading. You might be able to get money back in your Social Security check because the Medicare advantage plan pays a portion of your part B premium, but you need to know what Risk you are taking on to get that small amount back. There is nothing wrong with using a Medicare advantage plan, but you need to understand exactly how it works and what the requirements are before you make that decision. You should talk to an experienced agent to find out how the plan will work for you.

Answer: Some insurance companies offer a spousal or household discount. When one member of the household passes away, the discount is no longer extended for just the one person left in the home.

Answer: Yes, but you always need to have a discussion with your doctor when preventive tests are ordered, to be sure that they are coded for claims payment as ‘preventative’.

If you’ve had a prior diagnosis of abnormal breast tissue, for instance, future mammograms that are performed to keep an eye on that issue will no longer be ‘preventative’ but rather ‘diagnostic’ in nature.

The same is true of an A1c test for diabetes. As long as your A1c is normal, future tests to make sure that you haven’t developed diabetes should be coded as ‘preventative’ but as soon as you have a reading that indicates diabetes or even ore-diabetes, future tests will be diagnostic.

Preventative tests are generally paid at 100% by Original Medicare and Medicare Advantage while diagnostic tests are generally subject to your deductible and paid at 80% with Original Medicare, or subject to the plan benefits and copayments with Medicare Advantage.

It’s much easier to check the codes before the test is done than it is to have them changed afterwards. Busy doctors can easily make errors in this type of order, so asking them before they write the order is a good idea.

Answer: I would change the people running it. There are ways that we could make original Medicare work efficiently for all patients without needing it to be so confusing and without needing to split it between original Medicare and Medicare advantage. If we put professional managers in charge of Medicare, who are tasked with making it run smoothly and efficiently, it would be a very different system than we have today. our government simply is not equipped to run a healthcare payment system for millions of people.

Answer: The only way that you can avoid these charges is to reduce your income, at least two years prior to starting Medicare benefits. That requires advanced planning and possibly lifestyle changes that most people are not aware they need to make or prepared to make. IRMAA charges Are not designed to be avoided or mitigated. They are designed to bring additional money in to prop up a failing system. That said, when you retire and start Medicare, you often have a reduced income. That reduced income can be the basis of an appeal of IRMAA charges. Filing an appeal is easy, but requires that you gather some paperwork and submit the appeal on a timely basis. Education about the IRMAA is important to reduction and mitigation of these charges. Too often, Medicare beneficiaries who are charged with IRMAA fees are completely unaware that such fees exist until they receive the letter telling them that they must pay more for their Medicare part B and/or part D benefits.

Answer: In my opinion, the worst decision that someone can make is to ignore Medicare completely. Some people do not understand how Medicare works or what their benefits could be, and therefore choose not to do anything. There is a specific window of time when you turn 65 or when you leave your employer’s insurance when you may sign up for Medicare. Ignoring that period of time and doing nothing will mean that you are uninsured and have to wait to get Medicare until the following year. You will also be penalized if you do not have other creditable coverage while you are waiting for your Medicare benefits to begin. If you are over 65 and not receiving health insurance from your active employment or your spouse’s active employment, Medicare is almost certainly the best option for your health insurance needs.

Answer: In my experience, choosing a Medicare supplement insurance company with an ‘A’ rating from A.M. Best is probably your best option. Theoretically, these companies should provide the most stable rates overtime and the best benefits outside of the standard Medicare contract, like discount vision, plans, discount, dental plans, or gym memberships. Dmaller, lower-rated insurance companies are more likely to be purchased or forced out of the marketplace over time, making their sustainability questionable.

Answer: I have been working in the Medicare market for more than 20 years, and in that time I have had no client come to me and regret their choice to go into a Medicare supplement based on claims payment. I have had many Medicare Advantage clients come back to me and wish that they had gone with a Medicare supplement because their claims have become extremely expensive or they have found their treatment options to be limited by their insurance company.

My job is to educate my clients so that they can make the best decision for themselves. I do not push one option or the other. Every situation is different and every person faces a different path in pursuit of wellness as they age. Once that decision is made, my job changes to supporting that individual as they age and use the program that they’ve chosen. Sometimes, as a client ages and changes their mind about their plan, it is possible to help them move into a Medicare supplement, but most times the reason they want to make the change is because they are already sick. Once you have a diagnosis, it’s very difficult to move into a Medicare supplement plan and pass the medical underwriting process.

Answer: Yes. Medicare provides an annual Wellness visit, but reports vary from my clients about the quality and value of that visit, depending on the practice they see. It is NOT an annual physical. It may include vital statistics like height, weight and blood pressure, but my clients consistently comment that the nature of the visit is a questionnaire on safety in their home, with discussion about guns, throw rugs and hand railings on stairs. Most tell me that it is a nurse visit and they do not see a doctor.

Answer: Most commercials that I see on TV speak almost exclusively about the ‘extra’ benefits of Medicare Advantage, like dental, vision, grocery cards, OTC drugs and gym memberships. They do not talk about the MEDICAL benefits, which are the basis and purpose of Medicare. The ’extra’ benefits are not guaranteed from year to year and often do not make-up for the increased medical costs and risks of a Medicare Advantage plan.

Answer: In the past, Medicare Part D was simply a math problem for me - finding the plan with the combined lowest cost for my client’s particular medications and preferred pharmacy. That changed in 2025 with the implementation of the $2000 out-of-pocket maximum under the Inflation Reduction Act of 2022. We now need to look much more closely at formulary medications to protect our clients in the event that they need a future unforeseen annd very-expensive medication. The quality of the program must now be taken into account in addition to the cost of the premium and the medications they currently use. We need to consider how likely the plan is to work with our clients for a formulary exception or how likely they are to require prior authorizations or step therapies. Insurance companies with fewer restrictions are worth paying a higher premium for because only approved / formulary medications count toward the $2000 maximum out-of-pocket amount and formularies have become much more restrictive.

Answer: It is extremely concerning to me. The privatization of Medicare comes with for-profit insurance companies, making treatment decisions on behalf of patients and their physicians. I believe that all medical care should be provided in a not-for-profit environment.

Answer: The only truly definitive answer comes at the pharmacy when you pick up your medication. Accurate answers before you pick up your medication may come from your insurance company. You may call their customer service line to discuss your medication questions and coverage provisions. They will help you to know if the medication is on-formulary and if any extra approval is required through prior-authorization or step therapy. You can also ask them if there are similar medications that would be covered at a lower cost so that you may discuss those options with your doctor or pharmacist. If they are telling you something different than you expect, you can ask to speak to a supervisor to figure out why you’re getting a different price quote or coverage determination from your pharmacy or from their online formulary tool.

Every detail matters with Part D coverage - drug, dosage, formulation, quantity, diagnosis, pharmacy, specific plan, how much you’ve anlready spent toward your MOOP and prior-authorizations. Only when all of these factors align correctly can you rely on the quoted price as ‘definitive’.

Answer: How often do you think things get complicated between healthcare and health insurance? When that happens to you, would you prefer to figure it out alone or would you like some help? How much time do you have to make sure that you fully understand every coverage option and every new piece of legislation that will affect you? Do you see a professional for other complicated things in life?

Agents help you through complicated claims issues when they arise and have full time expertise about Medicare and the available plan options and legislation that will affect you. In most cases, they are paid by your insurance company and cost you nothing extra. Why would you not want an agent?

Answer: I start every meeting / conversation by asking questions so that I can gauge how to best-help my client. Every client is different with different needs and concerns. At the end of the meeting, I keep asking questions until I’m satisfied that my client has received and understands the information they want / need to make good choices.

Answer: The claims risk in Medicare Advantage is higher than it is in Original Medicare with a Supplement. The managed care requirements are also much more tedious, meaning that the insurance company must agree with the treatment plan before they provide coverage. As long as your need for healthcare is low, Medicare Advantage is great - it’s usually low-premium and the copays for healthcare services aren’t bad. But when you get sick and they start arguing with your doctor and denying the treatment plan he/she recommends, that delays care and causes stress. Also, as you use more frequent care, the copays for each service can really add-up and become expensive. Lastly, the limited network of a Medicare Advantage Plan can also be one a problem when you need care but the network doctor can’t see you for months or you need a bed in a Skilled Nursing Facility and there are no available beds in the in-network facilities. When you’re extremely sick, you want more options, not to be restricted. Medicare Advantage plans are restrictive by nature, to keep premiums low and to allow them to make a profit.

Answer: It might, depending on the plan you’ve chosen. Medicare Supplement Plan G will provide up to $50,000 of emergency benefits outside of the US. Many Medicare Advantage plans provide Worldwide emergency coverage. But the keyword is ‘emergency’. What if it’s not an emergency but you need to receive care? Are you willing to pay out-of-pocket or interrupt your trip and return to the US? Can you pay upfront and wait until you get home to submit your claim for reimbursement? If you can afford to travel outside of the US and you have Medicare, I STRONGLY recommend buying an International Health Plan for your trip. Hopefully, you will never need to use it. If you do need to use it, an International Health Plan will provide benefits to help you with translation, to help you find and get to a western trained facility, to pay upfront for the care that you need, and to help get you home in the event that you need a special flight for repatriation.

Answer: You should be skeptical of an agent who ‘pushes’ anything. Your agent‘s job is to educate you so that you can make the right choice for yourself. Medicare Advantage plans tend to pay higher commissions, so agents are more likely to ‘push’ those plans. But this isn’t about what’s best for the agent, it’s about what’s best for you. Find an agent who understands that and provides unbiased advice.

Answer: Probably yes, but there are a lot of details that go into this decision that you need to consider.

If you work for a small employer with less than 20 employees, Medicare will become your Primary coverage once you’re eligible and your plan at work will only pay what Medicare does not cover - usually deductibles and the 20% coinsurance. Some employer plans will only pay the secondary portion even if you never signed-up for Medicare, and that would potentially leave you responsible for 80% of the bill on your own if you have not signed-up for Medicare Parts A & B.

If you have an HSA that you or your employer puts money into, you must stop adding money to that account once you’re eligible and have Medicare - even if you only have Medicare Part A. For this reason, you might choose to delay enrollment into Medicare.

If you are paying a part of the premium for your health plan at work or if you have a high deductible, you may want to take Medicare instead of your coverage at work. It may cost less and/or cover more.

There are so many different scenarios that require careful consideration when you work past age 65 and become eligible for Medicare. You should speak with an expert before making decisions to be sure you’re doing everything correctly for the outcomes you want and to avoid penalties later.

Answer: The answer to this question depends greatly on where you live and how you access care. I am located in South Central Pennsylvania, close to the Maryland border. In this area, I believe that the best plan option for those who want Medicare supplement coverage his plan G because it offers a benefit called Part B Excess. In Pennsylvania, this is not an important benefit because our laws say that doctors who accept original Medicare must take Medicare assignment as full payment. However, because we are close to world class care at Johns Hopkins in Maryland, the Part B Excess benefit becomes important as it will pay a benefit in Maryland. In Maryland, and most other states, doctors are allowed to charge an amount over an above Medicare assignment and the Part B Excess benefit will pay in the event that a patient is charged the excess amount. This benefit could be worth thousands of dollars. In today’s economy, where things are changing quickly, and doctors and facilities are struggling, it is more likely that doctors who are able to charge for Part B Excess will do so. Another very popular plan in this area is plan N. I do not prefer Plan N because it does not have the Part B Excess benefit.

It is important for you to understand all the nuances of these plans before you make your choice. You should always speak with a Medicare Insurance Advisor to get good advice before choosing your plan. You might not be able to change your plan later.

Answer: This can be complicated and difficult to understand for some people. I look at it two ways to try to make it make sense…

1. Just because YOU are not paying a premium, doesn’t mean a premium is not being paid by someone else. For $0 Premium Medicare Advantage plans, the ‘premium’ is being paid by the US Government. They don’t call it a premium, though. When you choose a Medicare Advantage plan, Medicare is no longer responsible for paying your claims. Instead, the insurance company that you chose for your Medicare Advantage insurance plan is responsible for paying your claims, according to your policy provisions and in accordance with Medicare guidelines. This frees up money in the Medicare system that the US Government uses to pay the insurance company offering the Medicare advantage plan. There is definitely a cost.

2. You may not be paying a premium, but you will pay for the services that you receive according to your plan’s contract. Depending on the plan, you will be responsible for copayments, deductibles and coinsurance, up to the plan’s maximum out-of-pocket provision. The maximum out-of-pocket requirement on your plan is an important number for you to know. That is the point within the plan year when you’ve paid the maximum amount that you are required to pay, and your insurance company will pay the rest for the remainder of the year. In Pennsylvania, this maximum can range from $4000-$9000 per person per year, depending on the plan. So even if you are not paying a premium, there will be a cost to receive medical care.

Before you buy a plan, it is important that you understand what you are buying and how it works. Please reach out to a professional Medicare insurance agent for assistance so that there are no surprises at the time of a claim.

Answer: Well, first of all, in 2025 there is no longer a coverage gap (aka donut hole). So that’s the good news.

Instead of a coverage gap, you will pay your plan’s formulary tiered copayments until you’ve spent a total of $2,000 (in 2025) on covered medications. Once you’ve reached that Maximum out-of-pocket (MOOP) amount, you will pay $0 for covered medications for the rest of the plan year. Please note the key word ‘covered’. You will need to find out from your plan or your pharmacy whether or not your medication is covered and at what formulary tier and copayment. If your medication is not covered by your plan, it will not count toward the annual MOOP. It will also only count toward the MOOP if it’s processed through your insurance. If you get a better price by using a discount card, it will not count toward your MOOP.

If your medication is not covered, you can get a list of alternative options that would be covered and ask your doctor to prescribe one of those instead. If you absolutely NEED the medication that is not covered, your doctor can request a formulary exception to ask the insurance company to cover it anyway. In order for the insurance company to consider your request, you and your doctor will need to provide evidence that other treatments have been unsuccessful.

Getting the right prescription medication that works for you and with your insurance is a process. Then, once you’re settled into your plan, it will reset with plan, premium, pharmacy and formulary changes every year on January 1st. This is why it’s important to have a good Medicare insurance agent to help you through the process and changes each year.

Answer: No. When you have an HMO, there is no coverage for out-of-network providers except in emergency situations.

At the next Annual Enrollment Period, look for a plan that either includes all the doctors you want to see or a PPO so that you have out-of-network coverage. In the meantime, if you want to see that provider, ask if they have a cash discount and be prepared to transition to an in-network doctor if you need anything more than just a check-up.

Answer: I think that Hospital Indemnity Policies are a great idea in combination with Medicare Advantage. But please understand that the HIP will not cover every expense that you are exposed to in your Medicare Advantage plan. A good example is Physical Therapy. You may need 20+ PT visits at your specialist copay amount after a surgery or injury, and that really adds up. Another example would be chemotherapy / radiation treatments or yet another would be Skilled Nursing Care. These items would not necessarily be covered by a HIP but could cause you substantial out-of-pocket expense. Always talk to a licensed agent to learn what options are best for your needs before you purchase a policy.

Answer: Well, first, you need to establish if your plan offers coverage for out-of-network providers and who those providers are.

If you have an HMO, out-of-network services are not covered, except in an emergency. Doctors who are not contracted with the HMO are considered out-of-network, and in some cases, even if you are seeing a contracted HMO provider, the service might not be covered without the proper referral. HMOs are generally the most-restrictive of Medicare Advantage plan options.

Medigap has generally been considered the least restrictive of Medicare options because it uses Original Medicare. A decade or two ago, ‘everyone’ accepted Original Medicare, so ‘out-of-network’ wasn’t really a concern on Medigap plans. But times are changing and it is no longer true that all doctors accept Original Medicare. So, similar to an HMO, if you have Original Medicare and a Medigap plan, and you see a doctor who does not accept Original Medicare, you will have no coverage for that service.