Casey Ahlbum, Medicare Insurance Broker

Answer: Good news for you, the "donut hole" went away for good in 2025! All part D plans have the same structure now, a deductible and a maximum out of pocket.

The standard deducible in 2026 is $615 dollars (individual plans can offer a lower deductible but it cannot exceed this amount), and the maximum out of pocket is $2100.

Prior to reaching the deductible you pay 100% of the cost of your medicines through your plan at whatever co-payment or co-insurance is designated (based on the drug tier). In some cases that might be a $0 co-pay! Once you reach the deductible, the plan begins to pay a larger share of the costs (i.e. a $20 co-pay may now only be $10) until you reach the maximum out of pocket limit.

Keep in mind that the maximum only applies to covered medicines, so your choice of a prescription plan should be "prescription driven" based on the actual medicines that you take. Don't assume every Medicare Advantage plan's part D formulary is going to be the same.

For many beneficiaries, a Medicare Supplement plan with a stand alone part D plan can give you the best combination of medical freedom, lower long term costs, and the best available prescription coverage for the medicines that you actually take.

Answer: This is a common question. Zero premium is not the same as "free" because you still need to make your monthly Part B premium payment (plus IRMAA if it applies to you).

And even though you're not paying up front, you'll pay as you go with expenses like co-payments and co-insurance, up to a maximum out of pocket limit that is usually several thousand dollars (and even higher if you go out of network!).

In addition, there are other trade offs like strict networks and referrals, along with a prior approval process where the insurance company gets to decide whether or not they are going to pay for your treatment.

For many seniors, a Medicare Supplement plan with a fixed premium, can provide predictable costs, much more freedom when it comes to healthcare, and can protect your retirement savings for the long term. It's helpful to work with a licensed agent who will explain everything clearly so that you can see what truly fits best for you.

Answer: IRMAA is a monthly surcharge that is applied to your part B and part D premium if your income exceeds certain thresholds. They look at your Modified Adjusted Gross Income (MAGI) from 2 years ago to determine your potential IRMAA.

It's reassessed every year in the same way. Many retirees see their income change immediately when they leave work, and there is a way to request a readjustment of your IRMAA so that you don't have to wait 2 years for it to catch up.

This is one of those areas where it's helpful to work with a trusted guide who can walk you through it step by step.

Answer: Seniors who are still working and covered by a large group plan can delay starting part B and enroll, without penalty, if they've maintained proof of continuous creditable coverage.

The CMS-L564 form is used to document creditable coverage, it is signed by a representative of the employer, and is submitted with the application for part B.

For many seniors, it can make sense to delay starting part B, and the CMS L564 form helps avoid part B late enrollment penalties by documenting continuous creditable coverage.

Answer: A Medicare Supplement insurer can only cancel your policy if you fail to make your premium payments.

Answer: I don't recommend that anyone just have part A and B alone. There are some significant gaps in coverage, and no maximum out of pocket cost.

Adding a supplemental plan can be the best approach to cover those gaps, for most seniors, as the premiums are predictable and your retirement savings is protected against significant out of pocket costs. Seniors with Medicare plus a Medicare Supplement can see any Medicare doctor in the country, or go to any hospital, without worrying about networks or approvals.

Medicare Advantage can also help limit out of pocket costs and will cost less in the short term. However, advantage plans are known as "managed care" meaning that you have to stay within a network, they can require referrals and pre-approvals, plus you'll pay cost sharing (co-pays, co-insurance) up to a maximum out of pocket limit that must be reached before you're covered in full. Out of pocket limits will typically average $5000 to $7000 in network and much higher if any of your providers was an out of network provider.

For most seniors, the predictable costs, freedom of choice, and limited out of pocket exposure makes a Medicare Supplement plan the best long term choice.

Answer: The terms "Secondary" and "Supplemental" are often used on an interchangeable basis but they mean the same thing. They typically refer to a Medicare Supplement plan which works with Original Medicare, and pays second, covering the "gaps" that Medicare doesn't pay for under parts A and B.

People with Medicare Supplement coverage have the flexibility to see ANY Medicare doctor, anywhere in the country, they have a predictable premium, and out of pocket costs that are extremely limited and clearly defined by their specific plan.

For most seniors, this can prove to be the best long term approach to Medicare, as benefits are guaranteed and cannot be changed as long as premiums are paid.

Medicare Supplement plans only work with Original Medicare, they do not work with Medicare Advantage plans.

Answer: All part D plans divide drugs into different tiers, typically one through four. Tier one is typically your preferred generics, tier 2 is non-preferred, tier 3 is preferred brand name drugs, and tier 4 is non-preferred brand name. Some plans will also have an additional tier for specialty drugs.

Medicines that fall in tier one usually have the lowest out of pocket cost, while higher tier medicines require the beneficiary to pay a larger share of the costs. Each part D plan will have a different formulary, or list of drugs, and two different plans could have the same drug in different tiers. That's why your choice of a part D plan should always be prescription driven, based on the actual medicines that you take.

You can change your part D plan, if necessary, during the Annual Election Period (AEP) each year, between 10/15 and 12/7.

Answer: Every Medicare beneficiary gets a total of 60 lifetime reserve hospital days. Medicare covers hospital coverage for up to 90 consecutive days, per benefit period.

Starting on the 91st consecutive day and each day thereafter, the beneficiary will begin drawing from their lifetime reserve days. After the lifetime reserve days are used, there is no additional coverage for hospitalization, and the beneficiary is responsible for 100% of the costs. Lifetime reserve days can be used once and after that they are gone.

That does not mean that Medicare won't cover hospital stays in the future, during a new benefit period, it just means that coverage after 90 days might be limited based on how many lifetime reserve days are left.

Medicare Supplement plans will cover an additional 365 days in the hospital after the lifetime reserve days are used, making that a key part of most seniors' Medicare strategy.

Answer: Short answer: Yes, in some cases you can.

When you first start Medicare, you have a window of time where you can get any Medicare supplement plan on a guaranteed issue basis, with no health questions. Outside of that window, and some limited trial periods for Medicare Advantage, in most states you will have to answer health questions, and you can be denied.

That's why it's so important to look at all your coverage options when you first start Medicare and look at how you want your healthcare to work down the road, rather than choosing what works today and planning to change later on.

Answer: When you work with a good agent, you're working with a professional who is focused on helping find the right coverage for your individual needs. A good agent takes the time to get to know you, and kind of like a good doctor, lawyer, or accountant, they'll make professional recommendations that fit.

And, unlike calling the carrier's 800 number directly, a good agent will be there for you months and years after you enroll. And the premium is the same, whether you work with an agent or call carriers directly.

So while it won't cost you more to work with an agent, it might cost you more not to!

Answer: Under Medicare Advantage, you can pay co-pays or co-insurance for almost all services. It's important to use an in-network provider, and make sure you read your plans Outline of Coverage document so you know exactly what you might be billed for up front.

And consider a Medicare Supplement plan. You'll have a monthly premium, but your out of pocket costs will be very limited, defined clearly, and consistent year over year.

Answer: Most doctors that I talk with prefer their clients to have Medigap. It's easier for them from a billing standpoint, and they don't have to constantly wait for pre-approvals before they can provide care. With Medigap, they know that if Medicare pays, the Medigap plan is going to pay as well so they can recommend treatments with confidence.

Answer: That's a great question. In reality, waiting until after a diagnosis can often be too late.

Most people who are thinking of switching, almost always want to switch to a Medicare Supplement plan once they have been diagnosed with something. Unfortunately, in most states, you have a limited "guaranteed issue" window and once that passes, you'll have to answer health underwriting questions.

Depending on your diagnosis, you might be uninsurable at that point, making it difficult or even impossible to switch.

That's why it's so important to consider all of your options, and to think beyond just asking "what's the premium" to considering "how do I want my healthcare to work down the road if I get sick?" A good Medicare Advisor will help you answer those questions so that you have coverage that will meet the test of time.

Answer: When it comes to enrolling in Medicare, there are really two paths you can take.

You can enroll right when you turn 65, or you can enroll later, if you’re still working and covered under a qualifying employer plan, typically one that has 20 or more employees.

If you’re enrolling at 65, you’ll use what’s called your Initial Enrollment Period. That’s a seven-month window that starts three months before your birthday month, includes your birthday month, and continues for three months after. That window matters, because it’s how you avoid late enrollment penalties, especially for Part B. Collecting Social Security already? Then you'll be enrolled automatically.

If you’re still working and covered under a larger employer plan, you may not need to enroll right away. You can delay Part B without penalty. Then, when that coverage ends, you’d use a Special Enrollment Period to get enrolled. In this case, it's a good idea to enroll about 3 months prior to your anticipated retirement or Medicare start date.

The key there is simple, you just need to be able to show that you’ve had continuous, credible coverage the whole time. You'll have your HR or Benefits department help you fill out a Proof of Creditable Coverage form and submit that with your application for Part B.

This is one of those areas where the timing really matters, and getting it right upfront can save you a lot of headaches down the road.

Answer: Not necessarily. Advantage plans have "gaps" too, we call those co-pays, and co-insurance. I don't recommend that anyone choose Original Medicare alone, you need to pair with with a Medicare Supplement plan that will cover the gaps and protect your retirement income against those out of pocket costs.

In many cases, Original Medicare with a supplemental plan can offer a lower out of pocket than what you might find on an Advantage plan, while also giving you more freedom and flexibility.

Answer: Sometimes, a part D plan with a premium, can offer a lower total out of pocket cost (medicine cost plus premiums) for a specific list of medicines.

Every situation is different so it's important to run your specific medicines through the plan finder, and look at different pharmacies, to see which path and plan are the right one for you.

Answer: The best way to save money on your Medicare Supplement is to work with a trusted independent advisor who can work with multiple companies. And, don't just assume that plan G is the best plan.

A trusted advisor will help you understand the different plan choices, plan G, plan N, plan HDG, and more. And then they'll look at companies that focus on stable premiums over time, good customer service, who are rated strong financially, and who have an established track record.

When looking at a Medigap plan, or Medicare Supplement, it's important to look at possible costs over time versus just this year's premium. In most states, you only have six months from when you activate your part B coverage to enroll in a Medigap plan without having to answer underwriting questions. There are some exceptions around advantage trial rules and some states have adopted "birthday" rule that allow you to switch, but that is the general rule.

A trusted advisor is going to help you choose the right plan for the long term, not just the cheapest one for right now.

Answer: Original Medicare and a part D plan has a number of benefits for people who travel. With Original Medicare and a supplemental plan, you can see any doctor, anywhere in the US who accepts Medicare. There are no networks or referrals to navigate.

And a stand alone part D plan allows your choice of plans to be prescription driven, so that you can fit the plan to the medicines you actually take.

Advantage plans are network based, meaning that if you travel, you may be outside of your coverage area. This can be inconvenient when you need care. And, with Advantage plans, you have to make sure all of your doctors, and hospitals are part of the plan, and that the prescription plan's formulary also covers your medicines.

Answer: People usually don't ignore advice on purpose. Most of the people I work with are trying to make the best decisions that they can, with an awful lot of noise coming at them from multiple directions.

They are seeing celebrities in ads on TV that promise "extra benefits" or allege that they're "missing" part of their benefits. They hear different opinions from friends or loved one or they're focused on just the premium without understanding all the trade-offs.

People have a natural tendency to stick with what feels familiar or easy in the moment, even if it's not necessarily the best for the long term. Medicare decisions have consequences that often don't show up right away, and when someone doesn't realize this it's easy to go in a different direction.

My role as an advisor is to cut through as much of that noise as I can, so that they clearly understand their options and can make clear, confident decisions for the long term.

Answer: Yes, Medicare covers Telehealth. In fact, according the Consolidated Appropriations Act, signed in February 2026, extended most of the COVID era Telehealth benefits through December 31, 2027. That means medicare beneficiaries can continue to receive Telehealth services Medicare COVID-era telehealth flexibilities were extended through December 31, 2027. This means beneficiaries can continue to receive services, regardless of location, through the end of 2027.

Answer: Medicare Advantage is a network based managed care alternative to Medicare. The government pays a private company to provide your Medicare benefits. You're essentially opting out of Original Medicare, and that private company becomes the gatekeeper for your health care benefits.

They usually have lower premiums than Original Medicare and supplemental coverage but there are trade-offs. Network restrictions, referrals, and pre-approvals become an every day part of life on these plans, and there are pay as you go expenses in the form of co-payments and coinsurance that can add up significantly.

With Original Medicare and a supplemental plan, you can see any doctor who accepts Medicare, anywhere in the US, and go to any hospital. If your doctor approves a test or treatment, Medicare is generally going to pay for it without requiring approvals first. Medicare pays its share of the costs and the supplemental plan covers the "gaps" leaving you protected against those higher out of pocket costs that are commonly associated with advantage plans.

Neither choice is right for everyone, but Original Medicare with a supplemental plan typically offers the most freedom and the best long term protection for your retirement income.

Answer: Original Medicare doesn’t cover hearing aids or the routine exams, so there isn’t really a workaround within Medicare itself.

Some Medicare Advantage plans include hearing aid benefits, but they usually come with network restrictions and the coverage can be very limited, so there's a trade-off.

Many retirees stick with a Medicare Supplement for more freedom and predictable costs, and then use options like discount programs or newer over-the-counter hearing aids to manage the expense out of pocket. And membership clubs like Costco and Sams, can also be a great resource for affordable hearing aids and exams.

Answer: Technology will put more information in the hands of Medicare beneficiaries. While that is generally a good thing, it may also cause information overload.

Trusted Medicare Advisors, those who take the time to get to know their clients and provide long term solutions, will become an even more valuable resource to help guide seniors through an overwhelming amount of options.

Answer: Medicare doesn't cover routine exams for things like glasses and contacts. However, it does provide coverage for more serious issues like glaucoma treatments, macular degeneration, and cataract surgery (the traditional surgery, not the laser).

Many seniors elect to pay out of pocket for their routine exams, or obtain stand alone vision and hearing coverage. There are a number of discount optical providers, and even membership clubs like Costco and Sams that can provide affordable options.

Answer: If you're on disability due to an accident, you'll be eligible for Medicare after receiving disability/SSDI payments for 24 months. The clock starts when you begin receiving disability payments, not on the date of the accident.

In month 25, you're enrolled in part A and part B automatically, and you'll get your card in the mail a few months before your Medicare start date. And there's a couple of exceptions: If you have ALS (Lou Gherig's Disease), Medicare starts immediately. And if you have end stage renal disease (ESRD) the timing can be sooner, depending on treatment.

Quick example: If your disability/SSDI payments began in June of 2025, your Medicare would begin in June of 2027.

Answer: This is a common concern. Dental coverage is a popular Medicare Advantage benefit, but it is not part of the core medical coverage. Most plans will have a limited allowance with an annual cap on benefits, and this is one of the benefits (along with things like gym memberships and over the counter allowances) that typically get impacted first when the plan tries to reduce costs.

My advice is that you should never sign up for for a Medicare plan based on any of the extra benefits (dental/vision, gym memberships, etc). And in most cases I find that seniors are much better off with a stand alone dental plan that is tailored to their individual needs. By de-linking medical from dental, you can choose the right plan for your medical coverage and then secure separate dental coverage as well.

Answer: Treating Medicare as another annual enrollment decision that they can do on their own, rather than looking at it as a long term strategic decision.

The decisions that you make when you enroll in Medicare, will follow you all throughout your retirement. Too many people make decisions based on TV commercials or well meaning advice from friends and relatives, but Medicare is not one size fits all.

Some plans limit the doctors and health care providers you'll be allowed to see. Others don't travel well, and some require approval from the insurance company before you can get care.

Certain plans may look inexpensive up front, but hidden out of pocket costs can end up costing you thousands if you have a serious health issue. Others may cost a little more up front, but offer much greater freedom and flexibility while limiting your out of pocket expenses.

There's no right or wrong approach, and a trusted Medicare advisor will take the time to get to know you and guide you through the process so that your plan choice fits your life not just for today, but for the long term.

Answer: Medicare actually does cover many clinical trials, and it’s important to understand how the coverage works. In many qualifying trials, Medicare will pay for the routine care costs you would normally receive, things like doctor visits, hospital services, labs, and imaging. The experimental treatment itself is usually covered by the sponsor of the study.

Before you sign up, you'll want to make sure your specific trial is Medicare approved, and know which parts Medicare covers versus which parts the study covers. You'll also want other make sure that your Medicare plan gives you access to the doctors and facilities running the trial, since certain plans have networks that might limit you.

Beneficiaries with a Medicare Supplement plan will have the most flexibility, since they can typically see any doctor who accepts Medicare or go to any hospital.

Answer: It's best to start looking at Medicare ahead of time, before you'll need it.

As a general rule, whether you're during 65, or coming off of a group plan, that 3-6 month window before you plan to start is the "sweet spot". You can enroll up to 3 months prior to your 65th birthday, or the date you plan to retire, and starting earlier gives you time to understand your choices, so you don't rush into a decision.

For people leaving a group plan, you'll need to take an extra step and make sure you have proof of continuous coverage, so that you qualify for a special enrollment period, and so you can avoid late enrollment penalties.

A good advisor will help you walk through the timing, and help you determine whether you need to enroll at 65, or whether you can delay starting until later.

Answer: Medicare isn't just an enrollment decision, it's a strategy decision that will quietly affect your life all throughout your retirement.

The choices you make when you start Medicare will determine which doctors you'll be allowed to see, how freely you'll be able to travel, which hospitals and other providers will be available when you need care, and how well your retirement income will be protected when a serious health scare happens.

A good advisor takes the time to get to know you, and they will guide you through the process step-by-step, based on your doctors and prescriptions, your lifestyle and goals, and your level of risk and exposure.

One thing a lot of folks don't realize is that working with a Medicare advisor doesn't cost you anything extra. The plans cost the same whether you sign up on your own, or with help. The difference is, with a good, trusted advisor, you're not navigating it alone, and you've got someone in your corner for the long haul.