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.