Charise Karjala, Medicare Insurance Broker

Answer: What are the disadvantages of HMO Medicare? Well, by speaking of HMO Medicare generally, we're referring to most of the Medicare Advantage policies that are available in the country. These are managed care, which means that we're within a limited network of providers and that we need to follow the rules, the procedures, and regulations to stay in network with that provider network.

So, what are the disadvantages? I'd like to answer this in the other way around. What are the advantages? The first advantage is that you're not self-administering your medical care. You can rely upon a system to administer your benefits according to the CMS regulations, and there's a lot of clout behind that. If it doesn't go your way, you've got grievances, appeals, and you can go to the Department of Managed Care to complain to, which has very large sticks. Your protections are great using managed care.

Now, the disadvantages are that you can't pick your doctor. You may not be able to go to a private hospital electively. There's a number of other issues, especially if you're trying to get diagnostics and you've got a limited diagnostician within your network. Then you're going to be somewhat limited.

However, here's my strategy, and I just worked with one of my clients on this. He's spending $5,000 a year on premium only. He needs to see two doctors. It doesn't make much sense financially. So we did the math, and he is going to go into a managed care HMO so that he has 100% protection, no matter what happens in an emergency. He has $5,000 left over to go and see whichever doctors he chooses, whether that's a chiropractor or, in his case, a mental health provider, and he can choose to spend that five grand however he wants.

And he still has all of the protections of good Medicare. So there you go. That's something to think about. So not just disadvantages. It all depends on how you want to skin that cat, so to speak.

Answer: I love this question. The question reads, "How do I make sure that I'm not overpaying for my Medicare plan?" I'm sure there are tools and resources you recommend. Well, I'm going to limit this conversation to the Medicare supplemental policies, which are the ones that you pay for and that are renewable during your birthday month.

The best resource you have is to hook up with a broker, somebody who has experience and represents many different carriers, and have them shop your plan during your birthday month. That's the time when you have a guaranteed issue, and you can change carriers who have the exact same or slightly different policy for a different price.

And that is something that you can do every year during your birthday month. So you need, number one, a good agent or broker that represents five, six, seven, or eight different companies. Number two, contact them. Develop a relationship with them so each birthday month, every year, you can go through and shop your plan. And number three is finish this documentation and get that plan changed as soon as possible. That's it for now.

Answer: This is an interesting question. Is it okay to work with a younger Medicare advisor? Well, it's funny. We're not even permitted to call ourselves advisors, specifically Medicare Advisors. Those are the people that work for Medicare. So if somebody is calling themselves a Medicare advisor, they've overstepped their boundaries of what their real role is. They are a sales agent.

So if you've got somebody who's new and calls themselves a Medicare advisor, I would just run the other way because they're overstating their qualifications. So in other words, no, it's not okay. And in that circumstance, now if you've got somebody who is long in the tooth and has been doing this for more than about 15 years, that person may have informally earned the stripes to know their stuff well enough so that they can actually advise. But they can't tell you what to do without a thorough needs analysis.

So one always has to submit themselves to the scrutiny of a peer who's going to ask you a lot of questions about your needs, your budget, your doctors, your hopes and dreams, and your family history. That's what good Medicare agents do. They completely understand your needs from a 360-degree view and based on the finances, preferences, needs of your spouse, time constraints, financial constraints, drug access, access to specialists, and access to private hospitals that don't accept Medicare Advantage. Those are just a few of the questions in the algorithm that comes out with your top three options.

And a Medicare advisor or somebody who works for Medicare, they don't do that. They read off teleprompters. Those of us who've been doing this for a long time know how to get to the bottom of that in about a 25 or 30-minute conversation. It's not easy. You gotta know what you gotta ask. And if you're the client, you need to be patient and answer the questions.

So your advisor, agent, broker, or whatever you choose to call that person, not what they choose to call themselves, can best present three, four, or five different options to you, each with a price tag, each with a list of doctors, and each with some alternative scenarios.

So for example, I'm suggesting to many of my clients that they also have a concierge physician alongside their Medicare Advantage policy. So they have access to real doctors who will spend real time with them rather than the HMO model that now gives them seven minutes per visit.

Answer: Great question. It states every year I stress over picking a plan and still end up surprised by the bills. Is there any way to just get peace of mind with Medicare? Well, yes. Work with an agent. Work with a broker or an experienced broker that can explain everything to you so there's no hidden fees. Have that broker line you up with a very reputable company that has 4.5 or 5 stars, maybe even 4.0 stars. Filter through the background of it. Look at what kind of commercials they're doing on TV and how foolishly over-promising they are.

The seniors. So I would suggest if you're trying to get peace of mind, submit yourself humbly to an agent who is a professional and has spent years developing their craft. I have an MBA, I'm a certified financial planner. This is my humble little world where I service people, and it's my pleasure to do it. And it pains me to read that people are still churning through trying to find what's the next best thing when there is no one best thing. There's just one best strategy for you, your needs, and your budget.

At this time, it's at that point we then take a look at that and we go into a plan. See how that works? If it works, well great. We're gonna stay in it for a little while until your needs change or you've got some extra money and you want to be able to see some pushy doctors at City of Hope or somewhere like that. Let's do that. But when you understand clearly what your needs are and why you're choosing that plan down to the dollars and the exact doctor there, there will never be a question.

With my clients, there's never a question. And they know we can always change. So please follow some good advice. Get a great broker. Don't listen to these sales agents and you'll be much, much more settled. Happy.

Answer: I love this question: Why do some agents push Medicare Advantage plans over Medigap? And should I be skeptical? Yeah, be skeptical. Be very skeptical. Medicare Advantage plans for sales agents are incentivized for sales. Many younger agents only have a contract with one or two Medicare Advantage companies. So they will sell you hard on Medicare Advantage. They'll tell you all of the wonderful things that may or may not be true about that Medicare Advantage policy.

One case in point was a fellow I had as a client who came to me for a second opinion. He said, "Why did this happen?" He had bought a policy from an unknown, unnamed company. If you call me and ask, I'll tell you who it was. But it was a large name, and it looked like he had no copays. Here, I got a few dollars back on Social Security, and it was all looking just dandy. And so he signed up.

This man had just above the medical threshold for income, which, as you're probably aware, is very, very low. Then he ended up in an emergency situation where he was held up to the High Desert Medical Center, and he was graced with a $5,800 bill. A $5,800 bill for somebody who lives on approximately $1,600 a month. If that man had been appropriately placed in a policy with a different carrier, he would have paid $150 or $200. That's it. That man was sold a policy.

So that's what these people do: they sell you stuff. They're not doing a full needs analysis. They're trying to meet their metrics. They're trying to get 100 done. If you knew how much money people were making by churning through policy changes every year without the thought of a long-term strategy for the beneficiary, you would want to be sick. I'm sick of it. I'm sick of listening to the commercials on TV that tell little old ladies they'll get free money. It's dreadful. It's absolutely dreadful.

So here's the deal from my opinion: if it sounds too good to be true, run away. Go find a broker that's been doing this for a long time. Like I'm talking 15 years. That represents at least ten different companies. That works in probably more than five or six states. At that point, you've got somebody who's been around the block a little bit.

Answer: This is a very interesting question. It reads, "I've heard that once you're on Medicare, you might not need life insurance as much. Is that true?" Well, if life insurance is needed before we turn 65, why would we not need it the day after we turn 65? Life insurance isn't health insurance. Life insurance is designed to pay for items that we can't be here to pay for, such as probate fees, taxes on the properties that we still own, paying our executor something, filing our taxes, paying off your credit card debts. Dying costs money. Life insurance is a tool that's intended to be used for a couple of reasons. Number one is liquidity. When you die, your money basically freezes. It can't be accessed until your estate is cleared. So if we have a small amount—I'm talking ten, twenty, or thirty thousand dollars in life insurance, which is easy to get for hardly any money—I'm talking $30 a month for a 64-year-old forever. That's how much it costs. You give your entire family or the people that love you and are responsible for getting you in the ground, so to speak, some money to work with. It's not tied up in probate. Dying is not a clean and easy thing to do. We don't just kind of expire and everything magically gets done. It leaves the people around you with a ton of work to do that costs money. So I do believe that there is a need. I also believe that you may want to provide something for your heirs if you haven't already done so. It's probably a little bit late. But if you have a half-million or a million-dollar permanent life insurance policy and you think, "Oh, I don't need this; I've got Medicare now," stop right there. Your heirs could use it, or your spouse could use it, or your grandchildren. So there are no hard and fast rules here. But if you have life insurance and you can afford to keep it, do so. It's a wise financial planning choice. You will not regret it.

Answer: Happy birthday! You're turning 65 soon, so you can enroll in Medicare three months prior to your birthday month, the month of your birthday, or the three months following your birthday month. It's approximately seven months, three months on either side of your birthday month. Simple as that.

I believe we can now walk into a Social Security office, or we can call the Social Security Department and request a telephone appointment. But that's generally speaking how we go about doing that. You're gonna be very pleased with Medicare as it compares to employer-sponsored plans. Some people who are coming off the exchange have a bit of a sticker shock, but the fact that you can have care with close to zero copays, either with Medicare Advantage or with a PPO, is liberating.

So you can finally be confident that you can get the care that you need, that you've wanted for a long time, without breaking the bank. So congratulations and happy birthday!

Answer: The question is, what should I consider when moving to Medicare from my employer-sponsored plan? The first item is budget. Your Medicare policy should cost you somewhere around $400, inclusive of your Part B premium, your supplemental G policy if you're 65, as well as a dental and vision policy. And that's it. There shouldn't be co-pays, co-insurances, or deductibles other than the Part B, so use that as your kind of benchmark. That, by the way, is pure PPO. It goes wherever Medicare goes—Mayo Clinic, Cedars-Sinai, Eisenhower, Johns Hopkins, Cleveland Clinic. Yes, you get the best of the best of the best.

The second item is that you get to choose if you want to participate in a Medicare Advantage policy. Those policies typically have a network, and there are managed care options. There are a few mapped plans that are PPO still roaming around out there, but most of them, in my experience over the last year, have been eliminated. So people are struggling to get into the place, which, of course, the Medigap policies are a perfect example of.

The third item is that Medicare does not cover eyes, ears, or teeth for whatever reason. Public policy doesn't seem to think that those things are important. I do, however, so I strongly suggest and recommend that my clients come and have a thorough evaluation of what they know to be true for their needs in the reasonably near future, and they secure whatever kind of insurance policies will give them some kind of return on investment or some kind of additional protection for each of those three areas.

There's so much for people to learn about with Medicare, but just understand first and foremost that Medicare is the biggest network in the United States. It's limited only to those people that participate in Medicare. And if you have a Medicare card and you have a supplemental card, you can go to anyone you want to see, regardless of city, state, county, or location. That's the fact. So when we compare that to employer-sponsored plans, generally speaking, our Medicare gap policy is substantially superior to that of an employer-sponsored plan. So if you're debating about getting off of your employer-sponsored plan...

Answer: So the question is, are x-rays, exams, or therapies done by chiropractors covered under original Medicare? And the answer is no, except for in one very narrow situation. That is, manual manipulation of the spine by a licensed chiropractor is approved to correct a subluxation or a misalignment. However, the only covered service from a chiropractor under original Medicare is a spinal adjustment. So the x-rays and any other therapies or pills, those all have to be prescribed by a primary care physician, a relevant orthopedist, or an osteopath. So that helps.

Answer: I'm so happy that this question has been asked. And round about, this is the question: At age 66, I have been diagnosed with bipolar disorder. What is the best way for me to arrange my Medicare so I can get the best possible care?

Okay, here's the answer. I want everyone to pay attention to this. We have the best possible mental health care, I think, on the planet, available at our fingertips with Medicare. We've got neurostimulation, we've got medication, we've got talk therapy. And as long as we've got a really good diagnosis and proof that a number of different alternatives have been attempted, there are such great innovations being made for mental health and brain health that Medicare can take care of. Without an insurance company getting in the middle.

So you know where I'm going with this. I want you to have Medicare and a secondary, flat out. You can get the best of the best for a couple of hundred dollars a month with no co-pays. I want this for you. So please reach out to a competent agent to get through the underwriting for a Medicare supplement policy. Or if you're under 65, please, at your 65th birthday, just go straight into a Medicare supplemental policy. It'll cost you maybe $200 a month, depending. You know, you all know that I work in California, but I also work in Nevada and Arizona and elsewhere. So you're all set. Be well. This is a great opportunity for your care.

Answer: Love this question. I'm disabled, I'm under 65, but I'm gonna be turning 65 soon. Do I have to reapply for Medicare? No, you just roll right over. It just rolls right over. You won't be issued a new Medicare ID number. I've had some people who lost their Medicare two months before their Medicare 65 age, which is just an organizational snafu, if you will. Because how do you become un-disabled when you're 64 and three quarters? It's just a ridiculous thing. However, that's not the question. The question is, what happens? Well, number one is that you still get Medicare, but you get an open enrollment period, another initial election period, which is when you're newly eligible. This means for those of you who couldn't afford a Plan F or a G when you first got onto Medicare as an under-65-year-old, because those policies are $350 to $500 a month, you can now go and get one for as low as maybe $150 to $200 a month. And these are those Boujee plans that pay for everything. One little deductible, no co-pays. Every provider in the country that accepts Medicare is in network. That is a beautiful thing. So I hope you'll consider that as an option. My name is Charise Karjala. I work out of Palm Desert, California. Please reach out to me, and I will have a coffee with you by phone or in person.

Answer: What a great question. And in an area that I know a lot about because my background is in orthopedics. So the question is, how do we know that Medicare will pay for my robotic surgery that's been recommended for my knee surgery and my specific anatomy? Well, here's the deal. If your doctor says that it's required and he's a Medicare doctor, and he's done all of his data collection and he's got the health history, and you've had other surgeries or whatever the other indicators are that have to exist for this surgery to be a procedure based on your diagnosis code, then you're going to get that if you're in original Medicare with a secondary. There's no question about it. There's no insurance company that's going to come between you and your doctor that's going to say no. If your doctor has a good diagnosis, excellent record keeping, all of the MRIs and scans, and all of that kind of stuff that are all up to date, and you've been compliant in meeting your commitments in terms of injections and precursors to the surgery, you've lost weight, or you've stopped smoking, or all of the things that they expect you to do because they're spending a lot of money on you, you don't want to not be a candidate for whatever reason. You want to make sure that you are a good candidate for this. And if you do all of that right, then Medicare is not going to deny you. If it's an appropriate diagnosis with an appropriate procedure code that's approved by CMS, it will go seamlessly.

Now, if it's an experimental procedure, like I've had people come and think, "Oh sure, I have a bone spur and they have this new procedure of doing what is it called? Stem cells." Do you know how many people I know that spent $10,000, $15,000, $25,000 on stem cells that have no efficacy around bone spurs? It's unbelievable. So truly, if you've got a doctor that knows his onions and has done all of the data, and he's been taking care of you for quite a while, and he knows how to code Medicare and get paid by Medicare, you know that he does want to get paid for his work just like me and you, right? He's going to make sure that happens.

Now, we haven't talked about Medicare Advantage. Medicare Advantage may or may not pay for that. They may want to see other options being considered. They may not have a surgeon in their system that has access to that equipment. And so it may be a no-go. In which case, what you need to do is get with somebody like me, Charise Karjala in Palm Desert, California. I will run your background, see the analysis, and make a recommendation.

Answer: This question is very interesting, and it's even sad that it needs to be asked. Isn't it suspicious? The question is, can Medicare Advantage plans offer incentives to enroll? Well, it's illegal to offer incentives to enroll. They can offer value, but they can't offer incentives.

Where I see this, and it really makes me angry, is when we have the national advertising programs that are going to be starting on October 1st, and they tell people that there's money available for food. It's just... I've cried so many tears over this because I get calls from usually senior women who are very, very poor, and they've been living on a compromised income for a very, very long time. And the people on the television told them that they can get money, and it's not true. They have to apply for Medicaid, and that's the money that they will get.

Now, some communities do have resources, but that's not typically through the Medicaid or Medicare programs. Now, another element that seems to be an incentive is, "I give back to your Social Security." So if you don't have Medicaid or Medi-Cal and you need to have a little bit of extra money, and they offer you that, you will get another $40 back onto your Social Security check if you enroll with them.

Be very careful. That $40 that you're getting every month, that $500 a year, may end up costing you $5,000 in co-pays. This is the structure of those policies. Or you may lose all your doctors. Be very careful. This more than ever is a very tricky time to be trying to select a health plan. And guess what? I want you to know this: if you already have a health plan or a Medicare Advantage plan, don't do anything during October 15th to December 7th because you have a whole easy breezy time between January 1st and March 31st where you can make a real decision with real agents like me that will spend an hour or more with you.

So that's my suggestion. Go nice to yourself this year. Don't buy into any of these incentives because there's always something bad that's going to happen behind it. Just don't believe it. And then take your time in January through March because that's a whole other open enrollment period. If you already have a plan, you can take your time. So promise yourself, be kind to yourself, turn the damn TV off so you don't get confused, and you can call me.

Answer: I love this question: what are the red flags when I'm searching for a broker to help me with Medicare? Well, the first red flag is if you can't find them anywhere on the internet and they don't exist. That's a red flag for sure, because that means they don't have a presence. They work behind something else. They may not even be an agent; they may be an agent assistant. And certainly, search their Google reviews. If they don't have five stars, that means they've really made somebody pretty mad at some point and haven't done right by somebody. And I don't want that to be you.

The third red flag is if it starts to feel like a timeshare pitch, right? They're trying to hard sell you on one plan, maybe two plans, or maybe the 12 plans that are all the best from the same company. By the way, no one company does everything the best. You need to look for an agent that represents at least five companies. There's at least ten companies in any given area, and half of them usually don't do a good job. Most brokers will pick the top five or maybe six or seven, just to be able to keep an eye on the ones that do bad work so that they can understand what they're doing.

And I have my least favorites. If you ever ask me, I will share with you other red flags. Oh, if they insist on coming to your home, they send you a little card in the mail saying, "Oh, I can come and help you," and you've already bought a plan and said, "Oh, I'll come and see you." There's ethics within our industry. So are you already working with an agent? Well, why have you not gone back to that agent? That's what we do. We honor the professionals that are in our community, and we encourage them to continue to have communication with their clients. Sometimes things happen. If that answer is, you know, they died or whatever it was, well then fine, I will talk to you. But I'm going to ask you that question because it's a courtesy.

So that's the other element of courtesy. And if that agent doesn't have the courtesy to ask you to come and have a cup of coffee in their office because they don't have one, or they don't have the courtesy to do anything other than meet you at your home or in a car at a coffee shop, go somewhere else. How are you gonna be able to really? And how am I going to be able to understand you if I go into your house with your dishes and your pictures of your grandchildren? I'm getting a lot of data that honestly, people in the sales industry, they use that against you. I don't want you to feel like that. I want you coming into my space so you can understand who I am and how I look at your world, because how I look at your world is important. I'm going to be helping you for a very long time.

Answer: The question is, I'm planning to delay Social Security until age 70, but I'm turning 65 soon. How does this affect my Medicare enrollment? Well, it doesn't. You go ahead and apply for Medicare. That's it. You can enroll three months prior to your 65th birthday at ssa.gov. There's a provision in there where you can say that you don't want Social Security, which is exactly what you want. You don't want Social Security.

Now, do you pay more if you don't have Medicare and Social Security at the same time? No, you don't. It's just that they're going to send you a bill instead of taking it out of your Social Security check. Okay, makes sense. So if you have an employer-sponsored plan and you want to evaluate whether or not you should keep that while you're delaying your Social Security, it's a very interesting cost-benefit analysis question, and each circumstance is very different.

However, unilaterally, when I run the cost-benefit analysis, people are blown away by the cost savings of using the Medicare system over staying with their employer-sponsored plan in terms of scope, breadth, access to care, and cost-effectiveness.

Answer: The statement that came in today was, I thought I was covered by my Medicare Advantage company while I was snowbirding, not snowboarding to Florida. And they weren't. So what's the scoop? Well, I would ask the question: Snowbirding from where? So are you snowbirding from Canada? Well, obviously you have to have travel insurance because you're not covered in the United States. But I'm gonna assume that you're snowbirding from New York or Cincinnati or somewhere like that. And in that case, when you have a Medicare Advantage policy, some of them actually include out-of-state coverage as long as you advise them in advance that you're going to be out of state.

Now, what does the coverage mean when you're out of state and you have coverage? Well, basically, if you get hit by a car or have a heart attack, something terrible happens to you, you have coverage from your Medicare Advantage company, your original Medicare, and your supplemental policy. However, if you choose to remain in that state and receive treatment and ongoing follow-up, you won't have coverage because that's not part of your original plan unless you have original Medicare and a secondary like a G, F, or N policy.

So the Medicare Advantage policies are designed for emergencies when you're out of state. Very few of them will accept any prevention out of state. So for example, you've been living in two states. Let's say you've been living in Ohio and you've been going to Florida for the last 40 years of your life, and you want to continue to have doctors in both places. You have to have either a Medicare Advantage PPO, which as of 2025 seems to be mostly going away. They were a delightful thing, but they don't work so well when the insurance companies go and cancel them. So that may not be an option for you anymore.

The best option is to have some kind of Medicare gap policy, an F, N, or G. The other option is, before the age of 65 or later on, you can buy, depending on which state you live in. You can buy accident coverage or emergency coverage or hospitalization or doctors' coverage supplemental policies for a couple hundred dollars a month, which you will more than make up your money with if you use them wisely.

Now, these are very specific policies, and I'm gone beyond the scope of the question of does my Medicare work in two states? And generally speaking, the answer is yes, but only for emergencies and no for prevention.

Answer: The question is, what is the best way for seniors to avoid falling prey to a Medicare scam? It's a difficult question because, well, those of us that live in this community know how important it is to be cautious. My first answer is to make sure that you can walk into somebody's office and assess their credibility by looking at their designations, meeting their secretary, and perhaps even knowing who they are in your community. There are many of us that do community-based Medicare sales. We work in this community, we live in this community, and what I absolutely detest is what is happening with large organizations like United Health Care going towards a call center sale system, which does not serve seniors in the least bit. I am deeply, deeply disappointed by that strategy.

I, amongst many other highly sought-after Medicare agents that work in the industry in our communities, have an office, support staff, and credentials. We have master's degrees, planning degrees, undergraduate degrees in finance, and licenses in many different capacities. We may be life underwriters, we may be financial planners, but these are the people you want to work with. These are the people that are available to work with you for the same price as some schmuck that's going to come out and sell you a plan by putting high-pressure sales on you to come to your home when you don't want them there.

So this person should at least be willing to spend 15 minutes on the phone without asking too many questions or making any premature closes. They should be willing to have a conversation with you just for the sake of having a conversation and then let you call them back if you'd like or if you would like to set a date in the future, maybe a couple weeks in the future. They should at least be willing to do something for you for free without trying to demand your Social Security information and your Medicare ID number. They may need that information to verify your benefits, of course, to see what kind of options may be available to you.

But I think the first thing to do is never do a close on the first sale. The second item is do not believe what you see on the commercials on television, ever. These people are lying to you. They are flat-out lying. There's a little bit of truth on a national basis, but in most communities, they don't have those policies available to you, especially when it involves free food. That's what Medicare is for. Medicaid is for.

Answer: The question is how can I tell the difference between an experienced Medicare broker and an inexperienced Medicare broker? Well, I think the first thing is when you meet somebody who is a Medicare agent, ask some questions about how they got into this business. What companies do you represent? How long have you been doing this? What's your background? How many companies do you represent? Those are questions that show the breadth and depth of the understanding of the Medicare agent.

The other thing that is a telltale sign for me all the time about somebody's capacity as an agent is if they say, "I do Medicare." Somebody does not do Medicare. Medicare is a profession that highly skilled CFPs like myself and MBAs like myself choose to work in. People who have degrees in finance choose to work in the very fine detail of protecting people when it comes to their health coverage so that they don't go bankrupt. That's our job, to make sure that you not only have access to the best possible care, but you don't go bankrupt.

And that's more for the under-65 concerning Medicare policies, which are pretty sewn up, but you can still get in very, very deep trouble. So, length of tenure, how many companies do they represent? How long have they been doing this? What is their academic background? Ask them for their ID number. You can look that up on the California Department of Insurance, amongst others. How many other states do they involve, and do they? Do they represent at least five or more carriers in each line of business, which is drug plans, Medicare plans, supplemental plans, dental plans, and vision plans?

Now you've got somebody who has something truly to offer you that you can't just go and get off the internet. Some people like to go off the internet and unpack and find things. But I think you get people like us who have been doing this for 20 years, and we have advanced degrees and the wherewithal. We've been working with families for years. Why would you sell yourself short and not use a professional? We don't cost anymore.

The other item is if that person is dying to come to your house and knock on your door, run the other way. That person needs to have an office if they are a legitimate person. If they work from their kitchen table, they are a low-budget person. Get a good agent.

Answer: So the question is, what happens when we can't have proof of credible coverage when we apply for Medicare? Well, the fact of the matter is that this problem doesn't really occur very frequently because most people don't want to go without insurance. Right? They just don't. So they stay on their employer-sponsored plan until after they're 65, or they stay with their spouse, and their spouse has planned for as long as they can. So, the spouse retires, or maybe they live in a different country and they have that kind of coverage that's in France, Japan, Canada, or the UK, and all of those are credible coverage.

So the credible coverage requirements are generally speaking, do you get to see a doctor, or do you go to see specialists? Do you get prevention? Is there medications? Is there surgery involved? And if any of the answers to that are no, then, well, you don't have credible coverage. But most policies, legitimate policies, have credible coverage.

Now, I want those of you who think you can go and save a little bit of money. Right? And you listen to these people who call you on the telephone and give you high-pressure sales, do not listen to them. These people will sell you ice cubes to an Eskimo, and they'll say, "Oh yeah, it's all good." And you are so in trouble because they're lying to you. Don't listen to anybody who calls you up out of the blue saying they're from Medicare and they have a policy to sell you. Do not listen to them because those are not credible coverage. They have preexisting conclusions and preexisting conditions that are precluded. Most don't include drug plans, or they have a discount policy. It's not real insurance.

So be well-informed and be protected. And when in doubt, you know where you can find me. I'm happy to assist you.

Answer: Thank you for the question, which is how can I lower my Medicare Part B premium if my income drops after retirement? Well, great question, because this is a financial planning and budgeting question. So if you're preparing for Medicare, whether you're 40 or 64, just know that Medicare does charge a standardized fee, which changes along with the finance committee. So at present, it's $185. In 2025, it's set to go up to just over $200 for 2026. And that's the standardized Part B premium.

Now, if you make more money than $105,000 approximately, or about $185,000 if you're a couple, then you're going to pay more, and substantially more, upwards of perhaps even $600 per person if you're making in excess of half a million dollars as an individual or as a family. So the question being that how can I lower my Medicare Part B premium if my income drops after retirement? Well, that depends on what your baseline is. So if you're paying $600 a month for your Medicare and your income goes down below $100,000 a year, then of course your premium is going to go down. It's just going to be part of the calculation based on your income.

Now, the other option is to have a drastic change in your income, which means that as an individual you're making less than $24,000 a year, which is just dreadful. There are people that survive on that income. And in fact, they will pay very, very little, if not zero, for their Part B premium, which is our commitment as a society to take care of the least of us, the poor, and the disabled. So I don't want that for you. Obviously, I want you to be healthy and well and financially happy. But if your income does become very low, then there is an option for that.

And how do we access that? We have to go to our state, which administers our Medicaid benefits, and we apply with them. And we have to do what's called recertification every year, which shows them that we haven't become rich overnight. So it's a dreadful thing, and I don't wish it upon anybody, but it's there as remediation for those individuals that have low incomes. So I hope that helps. Thank you so much.

Answer: Call 1-800-MEDICARE and ask for a replacement. They are open 24/7. You will receive it in about 3 weeks. Take a picture of it and keep it in your phone for future reference.

Answer: The question is, how do I save money on my Medicare supplemental policy? Well, you've got it. Your birthday, every year, shop it. Because these Medicare supplemental policies are standardized, you've got L, K, G, F, whatever it is. They're all like Ritz crackers. It doesn't matter if you buy them at the fancy store or Walmart, it's the same Ritz crackers. So we shop it every year during your birthday month and make sure that you're not paying too much for it. That's how we do it. Use your birthday roll. Find a good agent. You don't need to do this by yourself, babe. You don't have to. You can get help. Find a good broker. Call me. We're here. I'm now saving people upwards of $600 or $700 a year just by doing an evaluation. Smart.

Answer: The question is, how do discount cards and resources affect my Medicare prescription drug plan? Well, the fact of the matter is that it doesn't. Your prescription drug plan is its own entity, as is a discount card or a resource, or using the Canadian pharmacy, or getting your stuff from Mexico or elsewhere. They're independent of one another. So the fact of the matter is that we've got a $2,000 cap on prescription drug costs now. That's effective January 1 of 2025. So as long as your medications are on your plan's formulary, if you spend up to $2,000 on your policy, after that everything is going to be covered. So the policy evaluation is what needs to be done. I want my clients to have the benefit of my skills to be able to go through and run the algorithm on the exact medications that they're taking currently so that we can project prescription drug costs for the following year or the reasonably foreseeable future, however long our time frame is. So sometimes my clients will see that a specific drug is best purchased from Canada Pharmacy or using a discount card. And that's factored into our analysis. So where people get into trouble is thinking that they can use a discount card in conjunction with their Medicare prescription drug plan. No, it's not going to work. It's one or the other. And some pharmacies won't even let you use the discount card at the same time. So just...

Answer: How did you know this is my favorite question? What are the six things that Medicare doesn't cover? Well, they are dental, vision, hearing, long-term care in a facility and at home, as well as skilled nursing facilities over 190 days. I will go into each of those briefly here.

So dental, for whatever reason, public policy doesn't think eating's important. Unless it's medically necessary, teeth aren't covered. We need to create a budget for that. Vision, prescription glasses, not covered. If you have cataracts or macular degeneration, that's covered by an ophthalmologist. So you need to have something in place for these.

Hearing, hearing aids are not covered at present. There's some pending legislation around that, but it has yet to get legs. So that's something else you need to budget for or have an insurance policy for, which I sell. By the way, I sell all of those policies.

Long-term care, either in a facility or at home, not covered. The only way we in California can get that is by attaching it to a life insurance policy or by having a standalone policy. So if you're 40 or 50, I wanna talk to you. If you're 70, not quite sure we can do something for you. There's underwriting involved.

And then skilled nursing facilities. After 190 days, you don't have any more skilled nursing. That's a problem. So these are things that we need to chat about well in advance of your 65th birthday. Be well advised. This is financial planning at its finest. Let's get together and understand what you need to know.

Answer: The question is, will I be penalized if I don't enroll in Medicare when I turn 65? No, you won't be penalized as long as you've got other health coverage. So if you want to spend $1,500 on a health plan for yourself, by all means, if you enroll in Medicare, you can get a great policy for about $400. So I would suggest enrolling in Medicare unless you already have coverage. If there's an employer-sponsored plan, that's credible. But be careful. There are lots of people who will try to sell you "insurance." But it's not. So be wise. Get well-informed.

Answer: Here's a question I get frequently: Is Ozempic covered by Medicare Part D for weight loss? Well, the simple answer is no, it's not covered for weight loss. It is prescribed for type 2 diabetes and we've got some other conditions as well. So if you go to your doctor and say, "I'm going on vacation and I want to lose 15 pounds," that would be a big fat no. However, if you've got cardiovascular illness or obesity and cardiovascular illness, and some type 2 diabetes pending, well then Wegovy, Ozempic, and trizepatide may all be options for you. I want to encourage you to be curious about these. This is the next generation of "wonder drugs" that has yet to be seen, but I'd like for you to continue asking, so hit me up.

Answer: What are the disadvantages of PPO? Two, number one, expense. You have to pay for it. Many people don't have any extra budget other than $185 a month. So they can't afford or don't want to pay for additional expenses. The second item is that there's no coordination of care. So for individuals with chronic illnesses, or who need case management, or who cannot coordinate their services on their own, the HMO is definitely superior. So I leave that with you. And that's it for now.

Answer: Yes.

You must be careful to make sure that the drug is on the plan’s formulary. As such, your cost will be included towards your $2000 maximum payment for all your prescription medications.

Answer: Super important question. How does Social Security and Medicare work together for people with disabilities? So Medicare is offered to individuals who are disabled. The caveat for that is that it is available to them after they have been eligible for Social Security for 24 months. I'll just use an example. One of my clients had a stroke a couple of years ago, 20 months ago. She's been trying to figure out how she's gonna pay for her premiums. Her husband's paying for them. They're very expensive. Given that she's just now been approved for Social Security, she's received a lump sum. She's got four more months of payments from Social Security, and at which point her Medicare A and B will take place. It's at that point where she can then enroll in a Medicare Advantage policy or a guaranteed issue gap policy. Now bear in mind, the gap policies under 65 are designed for people with disabilities, and as such, they are more expensive. That's part of budgeting that I have to do with my clients when they approach me with this exact question, that they have a family member that's become disabled. How did they get Social Security and how did they get Medicare? They do work together very, very well. At number one, we have to have a disabling event. Typically, that's a point in time that's diagnosed and documented through medical records, either through a hospital visit or through some medical notes. Then secondarily, we have to have a period of time to have Social Security benefits accrued, at which point we get Medicare 24 months after the fact. I leave that with you. This can happen for people who have mental health problems if they're in their 30s. Usually, that has to be accompanied with homelessness, unfortunately. But there's a variety of factors that result in the determination of disability. Note that disability can also be taken away. Fortunately, I've had several clients where that's happened, and it's devastating. This is another part of public policy that we need to be very aware of and know that it's not guaranteed forever. We need to be thankful for what we have while we have it. I leave you with that. Thanks. Good question.

Answer: You're retiring next year. Do you need to do anything with your Medicare? Of course you do. You're 65, yeah, for sure. You need to set a budget, get enrolled, and make sure that you have Part B active on the date that you choose to no longer work, at a minimum. That's what you need to do at a minimum. The next step is to do a reasonably good needs analysis and see what kind of plan you need in your community. Find a broker, run a budget, outline your preferred doctors, see what plans they take, and make a projection of the kinds of things that you need to have done in terms of teeth, eyes, ears, and your plumbing, if you will, and lay out an action plan. Most people defer maintenance until after they retire. So you'll probably have a bunch of doctor visits in your first year and do a good job. So yeah, get enrolled. On your 65th birthday, you get your A. As soon as you finish with your employer, you can apply for your B. And it's at that time you've got a couple months to pick up a plan. I probably will suggest that you look at a Medigap policy. I suggested G, but it depends on your state and your community. And you're welcome to hit me up.

Answer: This is a thorny question: why are hospitals not taking Medicare Advantage plans? The flat-out answer is that they can't afford to. Medicare Advantage, when they negotiate with the independent physician's associations, they are negotiating for 50% of the Medicare fee schedule or lower. So if Medicare pays, let's just say they pay $10,000 a day for whatever it is for the hospital to accept reimbursement under the Independent Physicians Association contracted rates, they might be having to accept $4,000 or $3,000 a day. And they can't meet their requirements for staffing, for safety, for facilities, for management, for cleanliness. They just can't do it. It's a rough place to be.

So we need to be careful, especially seniors that are moving outside of a given area because they want to go somewhere where there's less expensive real estate. I see people leaving from California to Arizona or to Nevada or elsewhere into these outlying areas, and there are no plans for them. The hospitals are small; they can't afford to accept the plans. They don't have economies of scale.

So that's the reason why hospitals aren't taking Medicare Advantage plans: we've discounted the fee schedule so much, not only for doctors who have been taking 2.5% cuts year after year after year after year, but the facilities as well. So we need to be mindful that we can only go so far with cuts before we're cutting access to care. And access to care is something that is legally guaranteed as a right for every one of us. And we're shooting ourselves in our own foot. So we need to have a good look-see at what we're creating here. Different communities have different resources. So we need to think about this very carefully.

Answer: I love this question. The question is, what happens if I delay Medicare Part A enrollment because I'm still on my spouse's employer plan? You kind of don't get to choose. It's happy 65th birthday. Boop. You get Medicare. It's not like you ask for it. B is something if you already have an employer-sponsored plan. No, just ignore that one. But A is free. A, you get happy birthday. You get a number. And when you don't want to have your employer-sponsored plan anymore, call me and I'll help you figure it out. But there's something to be said for engaging in Medicare. I run a cost-benefit analysis, and I've only had one case where I've done the math for my client. And they've said, yeah, I think I want to keep my employer-sponsored plan because it is so much more expensive and exposes my client to so much more risk. So if you've got A, you may as well get B. And then for $350 a month, you've got 100 percent coverage and hardly any deductibles. So that overshoots the mark on this question, but you get A anyway. So...

Answer: The question is about missing the initial enrollment period for Medigap and guaranteed issue. This individual claims they missed it by a few months and is asking why this isn't more widely understood. I'm not sure why it's not more widely understood. I know it's very well understood among those of us who work in this industry. So the question is, why are more consumers not asking about guaranteed issue? I think there's some confusion, perhaps leftover from healthcare reform, where there are no pre-existing conditions from 2012, the Affordable Care Act. But the Affordable Care Act does not affect Medicare. These policies, enrollment periods, and guaranteed issue have been very stable for the last 20 or more years.

So for those of you coming into Medicare, please don't listen to your friends, because they may or may not have accurate information. Call Medicare, call Social Security, call HICAP. There's an office in your state, or call a broker. Those of us who work with five or more companies, especially the big reputable ones—not the little ones—and who work in multiple states can answer that question quickly and efficiently for you. We can provide guidance, timelines, and budgets to work with. This is one of the most important decisions you will make in your life, and it shouldn't be left to a cocktail party or a poolside conversation.

I'm sorry to hear that this individual missed their Medigap window. If they were my client, I would certainly be looking for options to have a different election period where they might get a chance to move into a Medigap policy. But to miss that is a big miss, and that's unfortunate. The information's out there.

Answer: The question being which Medicare supplemental policies offer the best value for most seniors is fairly vague, in that MediGAP policies have the letters, as you're probably aware, they have F, G, L, M, and some other numbers and letters, sorry. I give them names to keep them straight, and because I work in a variety of different states, I can advise all of you that depending on what state you're in, the price of that policy is going to vary widely. So I could say that the G policy is the best way to go in, you know, in whatever county. But then we look at the pricing on that policy in a different county, for example, Washington state or Minnesota, and that could be cost prohibitive. So that's not necessary. The cost isn't standardized across the nation. So that's a very interesting one. We need to be mindful of that. There's no one rule there. The second no one rule is that most communities have a different configuration of private versus public hospitals versus, you know, charitable hospitals. So what's true in one community is not necessarily true in another community. What I mean by that is the overt charges which bring the reimbursement up to usual and customary for certain facilities that are private or certain doctors that don't accept Medicare as full and complete payment. So if that's the case, then obviously the cheap policy is really the only option for my clients. However, that may be too cost prohibitive if an individual is in an expensive area. So this requires, again, health insurance, Medicare is no one best way, and we need to stop treating it like that. We must do a thorough analysis of the individual's needs, the capacity of the community to meet those needs, and also their social resources, meaning money and time and treasure. So let's have a broader dialogue about this rather than either or the one best way. Find excellent assistance. Don't rely on one person. Don't rely on any one government agent. Find an excellent advisor in your community that can assist you. And we do it for free when we're brokers. So keep digging.

Answer: I've already answered this question, but it's near and dear to my heart because it has to do with durable medical equipment, which I seem to know a lot about because that was my business for a long time. Wheelchairs are considered to be durable medical equipment, and there's a 20% coinsurance on durable medical equipment up to the limits of the policy. So if you're ordering a wheelchair, it's $200. You get it by prescription only. By the way, you have to have a prescription, and you will probably pay $200 for it. So you may as well just go out to the local Walgreens or something and buy a wheelchair unless, of course, it has to be fit specifically for you by a seating and activity specialist. And now we're talking very expensive wheelchairs.

So the process of getting a wheelchair is to have a prescription, which outlines specifically what it is that you need it to do, whether it has little movers on it or a little tilt something back, or it has to have a particular kind of seat on it, or if it's just a rolling around the store one. So anyway, pay your $200, know that that's what it's going to be anyway, and get it done, or try to fight with your insurance company. That's kind of how it goes. That's it.

Answer: This question is, "Is original Medicare or Medicare Advantage better?" It's a bit of a red herring because it begs the question, better for who? Better for what? One needs to do a thorough needs analysis to understand what their resources are, what their needs are currently, and what their reasonably expected needs will be, along with the resources available in their community, to really determine the answer to this question. So this is not a blanket yes or no question. Unfortunately, in our discourse and narrative in this country, we seem to want to talk about it as either/or. And it's not an either/or. We have what I refer to as a three-tier system in our country. We have the Medi-Cal system or the Medicaid system, which serves the least of us. We have a commitment in this country to take care of the poorest of the poor and the disabled. Thank God we do that, and we do that efficiently and affordably. We have a commitment to do that, at least at this time. So that's our first tier. Our second tier is a hybrid tier, which is Medicare Advantage. It's subsidized through Medicaid, through Medicare, and through the insurance companies, and it's administered privately. So it's very, very efficient, and it meets the needs of the majority of individuals in this country because it's affordable. The system is largely managed care. There is some that is POS, which doesn't stand for poop on sticks; it stands for point of sale. So, no, it's a good system. The challenge there is that it's limited. It serves about 80% of the people most of the time. It's the 20% that misses the mark badly. So that's where we have the benefit of original Medicare. At this point, the individuals that choose original Medicare are those that have the wherewithal to pay for it and have the understanding, the conceptual understanding of the breadth and depth of the original Medicare system. In other words, we have the best damn medical system on the planet here that's available at our fingertips if we can pay for it. Most people want that. So it's up to the individual to determine what their needs are, what their capacity to pay is, and what their resources are. So there is no one best. Thank you.

Answer: There are three things I like about working with Medicare clients. The first one is when they're aging in, this may be the first time that a beneficiary isn't afraid of using a health plan. Under 65, health plans have deductibles and copays and all kinds of mystery, wherefores and therefores, exclusions and limitations, and out of network and approvals and non-approvals. It's terrifying for most 60 to 65-year-olds to be using a health plan. So much of their work, honestly, gets kicked down the road to when they turn 65. So it can be kind of an exciting time to go, okay, now we get to look at the LMNOP or the XYZ or the Hootie Hootie Water or the Zim Bambler or the Zing Wugler. So yeah, it's very exciting to finally be able to get the data that may have been kicked down the road because of fear of using a health plan that either they procured through the exchanges or through an employer plan. So that's the first thing that's exciting. Getting them into a plan affordably is really just so brilliant.

Second of all, I like to pivot them as their needs change. I like to work with their family members to have an open and honest dialogue about optimizing their health and looking at reallocating the resources towards perhaps items that aren't covered under Medicare for wellness, such as chiropractic or massage therapy or holistic health or supplemental health or travel, or being able to work with a budget so that the health of the individual as they age becomes optimized rather than just assuming it's going to get worse and throwing more money at it. It's really kind of being educated consumers about what's available.

And then thirdly, my last favorite thing to do is probably kind of twisted. But as our parents age, they require compassion and understanding, and family needs assistance to be able to pivot their resources as the needs towards the end of life occur. I love being a sounding board and an encourager and a cheerleader to empower families to take the reins of that and take advantage of some of the resources that are available through hospice and some of the more innovative legislation that exists in some of our states. So I really enjoy being a resource for wise use of scarce resources. So three things. Thanks for asking.

Answer: The most important question to be asking about Medicare is what it doesn't cover. We all know that doctor visits, hospitalization, skilled nursing, and operations, all that kind of stuff, is included in Medicare, thank goodness we have that. However, the largest thing that Medicare does not cover is long-term care, custodial care, dementia, Alzheimer's, where there's round-the-clock care that's required. We're told that $341,000 is the average amount that you and I, turning 65, will be required to pay out of pocket. So this is a question that 40-year-olds or 20-year-olds should be asking because that will be the age at which we can start to make plans to accommodate these needs. Right now, people who are turning 65 don't necessarily have the wherewithal and means to pivot and purchase general policies that can assist with long-term or custodial care because those are not covered. So that is the most important question that I should have been asking about Medicare that I probably haven't thought of yet.

So here's the deal. If you're turning 65 and there's nothing you can do about it, tell your kids who are 40 to get into a long-term care policy, to buy critical illness policies. And you, mom and dad, need to structure your estate so that it's protected and you can derive part of it to support long-term care, either in or out of a facility, or that you can protect your assets so you can utilize state resources, or finally that you have the means to pay family members to care for you. That's that. Great question.

Answer: Do they feel the same? Yes, of course they do, except you don't get a free overnight stay when you go to a Medicare seminar. You can't even get more than $15 worth of value in squeezy balls and pens and all that kind of stuff. So are they helpful? I think if the intention, like going to a timeshare seminar, is really wanting to learn more about the community, more about what the availability is, kind of getting a general lay of the land. And if you go with a friend who says, "I promise you won't sign up," just like a timeshare seminar, then I think they can be very, very helpful.

There are very specific rules around them. The sales seminars are intended to entice sales. There are Medicare 101 and educational seminars. I do them, and other agents do them as well, brokers. Those can be very, very helpful, especially when they're done in a small group or there's a Q&A, or you can submit a Q&A in advance. Then you can get some very specific feedback on your own circumstances.

So be aware that during those Medicare 101 seminars, they're not allowed to talk about any specific policy, which is kind of helpful. So if you're trying to make a decision between a Medicare supplemental policy or what's the new news on drug plans or where's the future of hearing aids going, those are all very informative. So I would say treat a Medicare seminar sales pitch like going to a timeshare. There's got to be something in it for you. Go with a buddy. Make sure you don't get sold. There you go.

Answer: I love this question. If a senior is turning 65 but still working, should they enroll in Medicare or delay it? This is a cost-benefit analysis question, and it's also presuming that the senior, the 65-year-old, has an employer-sponsored plan.

So here's the numbers on it. An employer-sponsored plan is probably costing the employer somewhere around $14,000 or $15,500 a month. Plus, the employee's portion is probably $300 or $400 a month. So you've got a couple thousand dollars a month that's going towards a health plan. It probably has a $4,000 or $5,000 deductible, a bunch of copays, and maybe there's dental and vision and all that kind of stuff. Maybe $50,000 of black insurance built into it. So the cost to the employer and the employee is somewhere around a couple thousand dollars a month with some risk.

Compare that to Medicare, which is $185 a month for your Part B. About another, let's just call it $180 a month for a Part G. Depending on where you're at, it might be Washington, it might be, you know, let's just even call it $200. We're now at $385. You've got a drug plan for maybe another $25. Now your dental and vision, maybe a life insurance policy, you throw that all together. That's the best possible insurance that you can buy with no copays, with one deductible of $200 a year. And it's around $400 a month. Doesn't that make sense?

Why would you continue with an employer's plan? Why? When you're exposing yourself to all of that risk, a limited network, and more expense to the employer? I like to think that as we age, we become more expensive to have around. And it's a bit of, I don't know, an insurance policy about getting laid off, if you will, because you're not as expensive as the next guy.

So those are just some things to think about. So cost-benefit analysis, think about it. $400 a month all together versus almost $2,000 a month for you and your employer. That's an easy decision. Thanks for the question.

Answer: Yes. Bone density is an important metric to watch over time. Decreased bone density can point toward illness that, when caught early, can be mitigated.

Answer: What are the reasons why I should work with a Medicare agent? I'm gonna divide my answer into two parts.

No. 1: Why should I work with a Medicare sales agent who works for a company versus an independent broker that works for a large entity like Health Markets and brokers for a number of different carriers? So, why should you work with a Medicare agent that works for Humana, United Healthcare, Alignment, etc.? I wouldn't. They're there to sell you a policy, and then the company follows up. If you have a problem, do you call your agent? Well, you could, and they may or may not call you back. They don't necessarily have an obligation to do that. They will more than likely have you contact the customer service department. There are some agents that will meet their commitment, but don't assume that they will. Most people don't even know the phone number of the agent they spoke to.

Now, let's go on to the second question: What are the reasons why I should work with a Medicare broker? This is somebody that works in the community, represents at least five companies, and has been doing this for a long time—probably 10 years. If you can find somebody like that, hit gold! This person can assess your needs and do a diagnostic of your situation—what doctors you see, what drugs you take, nearby facilities, family history, projected costs. If you've got a spouse, are they going to care for you if you become disabled?

So, I really get to know my client's whole situation, and we can pivot around problems that we can anticipate. For example, if we know you're going to need a couple of implants, you're going to need a policy that covers those implants. Then we drill down and find the implant policies. You need to find a good cardiologist who can do that valve replacement. Well, maybe we're going to go up to Cedars-Sinai or Mayo Clinic, or maybe we want to stay with our Medicare Advantage company and see which cardiologists are in-network and if they’re truly pros.

Working with a broker who is experienced and willing to dive deep with you can honestly save your life because they can anticipate your needs and provide resources as you need them, as your relationship evolves. It's about building a trusting, long-term relationship where they will care for you. So that's the main answer—caring for you.

Answer: This question is one that I have to answer in the negative. It is, can I switch from a Medicare Advantage plan to Original Medicare with a Medigap plan mid-year if I'm diagnosed with a serious illness? The answer is no, you just can't. There's no special enrollment period for that. If there is a special enrollment period, like if you move from one state to another, then yes, you can do that. In fact, I have had some of my clients do exactly that.

I'll tell you a story. A woman who had a Medicare Advantage policy in one state went to visit her grandchildren. At that point, she had horrible atrial fibrillation. She went to the hospital, they diagnosed her with A-fib, and they wanted to do a procedure on her. It’s a cardiac ablation, a pretty common procedure, and her insurance company said no because she wasn't in her service area.

So she came home, talked to me about it, and I said, "Hmm, maybe you want to move in with your grandchildren for a while." So she did. She moved back to the other state, got her Medigap policy, went to that wonderful cardiologist, got her ablation, stayed with the grandchildren for another few months, and then moved back to California to go back to her Medicare Advantage policy.

There's a tale, and there are ways around this. But if you get sick, you can't move unless you have a qualifying life event. Your policy doesn't go bankrupt, and you don't have a special election period. You can't do it; it's one of the limitations. So when you get into a Medicare Advantage policy each year, you want to make sure that that's what you want, that that's what you truly want.

So hit up your agent, hit me up, Charise Karjala. I'll do a policy review for you for free, and you can select your options every year. You can do this, and if there's a way to get into a gap policy without underwriting, let's do it if that's what you want.

Answer: This is a very interesting question to be on this platform because this is a Medicare platform, and the question is: What role do annuities play in retirement planning? This is best answered by somebody who has the credentials as a CFP, which I do, so I feel free to answer this question.

Annuities, if you don't know, are a lump sum of money that is kept in an investment account for a period of time where it percolates and grows in value. Then, at some point in the future, there's a triggering event, and the annuity starts to pay out. So, if you have $300,000 and by the time you're 72 years old you want to start cash flowing that annuity for, you know, $3,000 a month, that's kind of how it works.

There's capital gains paid on the amount that you distribute, which is part of the gains, and then there's no taxes paid on the original principal. Obviously, that's favorable for retirement planning because you've got a sock of money away, which is wonderful. But realize that it's not a tax-free source of income. Indexed universal life can also create an annuity through its accumulation period, but people who are doing that need to be probably in their 40s or maybe in their 50s. They will spend somewhere between $500 and $1,000 a month to accumulate upwards of maybe $800,000, which then is annuitized.

So, the $800,000 death benefit plus the accumulation is then annuitized tax-free. If somebody is telling you that you should buy an annuity when you're 40 years old and they're putting pressure on you to do that, I would look at other vehicles like indexed universal life, which grows tax-free and distributes tax-free.

So, that's kind of where it's at. If you're trying to create cash flow, obviously you want to make the most of your tax-advantaged opportunities, you know, for Roths and regular 401(k)s. I love health savings accounts for $5,000 a year for otherwise healthy people. That accumulates until you're a million years old; you don't have to distribute it. I also love indexed universal life because it can cover you for so many benefits: disability, long-term care, critical illness, advanced death benefit, or leave it to your heirs.

Answer: The question is, how does Medicare handle coverage for experimental treatments or clinical trials? Let’s be clear, Medicare Advantage is not going to pay for those. They’re just not going to, so know that. Medicare Original may pay for it, depending on how the procedures are coded and if it’s in the CMS regulations. There’s a lot of lobbying and fast tracking of drugs, and it’s far better than it was 25 years ago. If it’s going to be approved at all, it will be through Original Medicare and a supplemental policy.

So here’s the third option. If you’re under 65 in California, and even elsewhere, I can sell you a policy that if you get a bad diagnosis like cancer, or whatever, or LMP, or Leigh’s disease, or Parkinson’s disease, or whatever it is, you know, prostate, whatever, these policies pay you $100,000. You can go use your $100,000 to buy whatever drugs or participate in whatever clinical trial you want. It’s beautiful, but you can’t do it in California after you turn 65. I can sell them in other states, but you know, it’s just the facts. That’s why I want to have conversations with people before they turn 65, like when they’re 60, so that we can do the financial planning through this. We can look at long-term care. There is so much that Medicare cannot possibly pay for. It’s $341,000 is what you and I, when we turn 65, can reasonably expect to pay out of pocket for things like experimental treatments, clinical trials, and home care.

Answer: So this answer is in response to the question of whether Medicare Advantage plans cover dental and if individuals who enroll in those plans have problems finding a dentist. Is this a common problem? I would say, heck yeah! Most of the Medicare Advantage policies that have dental built into them are Delta Care USA, which is an HMO. It has large chain dental facilities that are in-network, and smaller boutique dentists, which most people prefer, generally can't afford to participate in the discounted fee schedule that the Medicare Advantage dental plans provide.

So, fancy pants dentists, you know, the good guys who do cosmetic and detailed work, take their time, and have a small practice, pay health insurance to their employees and take care of everybody. They can't afford to be doing work for fair 40 cents on the dollar, because that's about what these guys are getting paid. Let's just be real. If you have a dental plan that is with Medicare, by all means, try to find somebody that will do the cleanings, etc. Call the phone number on the back of your card and ask for a dental provider, but be very careful. Frequently, those dental providers are the ones who will try to bait and switch you into having dental work that's not necessarily required.

Most of my clients will come to me and take advantage of the embedded dental that is HMO, or some of the companies even have cash value. For example, Aetna has somewhere between $15 and $3,000 a year of cash benefit for dental, which is awesome. That means whatever you need to have done, dollar for dollar, which is very cool. But that's not all of them, so let's be clear. Many people will get a PPO plan on the side, which costs somewhere between $40 and $60 a month and will cover somewhere between $15 and $3,000 a year in tier 3 benefits. So it's not an uncommon problem, and it's just something we need to pivot around. Some people don't need much dental; they just need cleanings.

Answer: This is a super important question, which is, can I switch from a Medicare Advantage plan to a supplemental or Medigap policy during the annual enrollment period, which is October 15th to December 7th, without answering health questions? Generally speaking, if you've been in a Medicare Advantage policy, made a couple of changes over the last few years, and now you're 72 or whatever, and you're getting tired of this Medicare Advantage thing, the answer is pretty much a resounding no. You're going to have to go through underwriting with one of the carriers.

I won’t name which one, but they used to have what’s called an underwriting holiday, and they would invite everybody to come and participate in their Medicare supplemental policies without underwriting, which I just loved. I would have lists of people to enroll in their policy because they really needed to get in without underwriting, and I haven't seen that since COVID, unfortunately. So I pray that comes back so that, you know, people in my book of business or in my communities and states that I serve, I would like to be able to offer that to them.

But generally speaking, the answer is no. There are some circumstances where if people haven't been in a Medicare supplemental policy and they've only been in a Medicare Advantage policy for one year or maybe 18 months, yes, you can switch. But if you're anything over 70 years old and you want to make a switch, generally speaking, the answer is no. Check by state and by carrier because each one is going to be a little bit different. What may be true in California may not be true in Massachusetts.

That's the answer: generally speaking, no underwriting is something that we have to do. But these are private policies. Medicare policies are private policies; they're like life insurance policies. They’re provided to you based on where you live, whether you use tobacco—that's a big knockout—and medications that you’ve been taking. You may not even know that you were taking something for acid reflux, which could kick you out because it was an off-label use of a chemotherapy drug. So you never know what’s going to show up.

Here’s the answer: if you think you’re going to want a Medigap policy, get one when you turn 65 or 66 while they’re still cheap. Go and get all of your stuff done so you know exactly what you’re dealing with, and then when it becomes too expensive, then move out of it.

Answer: By far, the most underrated benefit of Original Medicare that many people overlook is how efficient it is at getting you to the front of the line with the largest number of doctors and facilities across our entire great country. Most people are so busy looking at the nickels and dimes associated with the Medicare Advantage policies, you know, that you get $500 of dental and you get $600 over-the-counter benefits, and they start counting that up. They think, "Well, it's gonna save me this much." I get it, our seniors are on a tight budget, so they compare that to having to pay another $155 for a G policy, another $5 for a drug plan, and maybe another $50 for a dental policy. They look at that and say, "Oh my God, I can't possibly afford that."

Here's the question I ask my clients that separates them from Medicare Advantage to Original Medicare: If you had something that was gonna kill you and there was one guy in the country, and he's over at Mayo Clinic or NYU or Cedars, or he's somewhere else, right? It's not in your community. Would you get on an airplane and go see him so he could save your life? If your answer is yes, that's the most important thing that's overlooked with Original Medicare. Yes, you're paying more, and yes, you might not even see a doctor that year, but yes, you have the choice to get access to the best medical care I believe on the planet. It's right at your fingertips. You do have to pay for it; it does cost a little bit. But with budgeting, knowledge, foresight, and planning, you can have access to the best of the best and not need a damn referral. It's brilliant. What a gift to our seniors!

Answer: The question is, can Medicare cover wearable medical devices like insulin pumps or seizure monitors for chronic conditions? The answer is absolutely yes, as long as they're deemed medically necessary. Typically, they're covered under Durable Medical Equipment, which has a 20% copay up to a certain maximum amount. Wearable medical devices like prosthetics and orthotics include wheelchairs, walkers, TENS machines, and all kinds of different things. So yeah, it's part of the Part B benefit. Generally speaking, most policies have a 20% coinsurance up to a maximum amount.

As long as it's deemed medically necessary and your physician has enough data to support the use of that particular device, and you've got a diagnosis from the ICD-11 system that says that prescription is relevant for that diagnosis, then by all means, you can get that filled.

Now, your Medicare Advantage insurance company might want to say, "Oh, well, we need to get a second opinion," or "We need to send that to this other supplier," which may not be the kind you like. So therein lies the challenge. You may have inconsistent quality of coverage in durable medical equipment, and I know that from experience. I've been in that world. The level of quality of care you get in durable medical equipment is vastly different, and it can be somewhat disappointing. So just get with your doctor.

Answer: What's the cheapest way to get Medicare coverage if I only need basic hospital care? My mother would call that pennywise and pound foolish, but I'll address the question anyway. How do you know that all you need is basic hospital care? I just don't get it. Medicare Part A is free, and that's the hospitalization. If all you want is Medicare Part A, then just have Medicare Part A and get free hospitalization. But know that you won't ever be able to go to a doctor's office without paying full price. If you end up at the hospital, you're going to have a big fat 20% coinsurance, which could be on a two million dollar bill. If you think that's cheap, well then I guess that's cheap, right? I don't know what the other option is. It kind of scares me to think about just not going to the hospital because it's too expensive. I suppose some people think that way.

We have Part B Medicare to prevent you from going to the hospital. That's why we have tests, exams, and specialists trying to prevent the advancement of disease that sends us to the hospital. The hospital is the most expensive way in the system to care for illness. Ideally, we use urgent cares. You don't have to take up a whole lot of space at a hospital; you can go to an urgent care. Then, if they say you need to go to the hospital, then you go to the hospital. I don't even know how to answer this question because it's so outside of my kind of concept. We have doctors, outpatient facilities, and urgent cares to prevent us from going to the hospital because the hospital is the most expensive way to get care.

Answer: This question kind of makes me crazy. It is, what should I do if I find out after the fact that my preferred hospital isn't in network with my Medicare Advantage policy? That's really unfortunate. Your main thing you'll need to do is wait until open enrollment the next time around and change to a different policy. Shame on your advisor for putting you into a policy where your preferred hospital isn't in network, or at least for not advising you that they're not in network with your policy so you can make alternative arrangements.

It's a really interesting question because some of the communities, my community has two public hospitals and a private hospital in the middle of it. Everybody wants to go to the private hospital. Generally speaking, people think they can go there, and they can, if they're showing up in the back of an ambulance or they've got a critical condition, or a car accident just happened and they've got blood everywhere. Yeah, they can go there and sit in the ER and wait, or they get triaged and off they go. It doesn't matter if your hospital is in or out of network; if it's truly a medical emergency, you're going to be taken to whatever hospital is closest and has appropriate care for you. If it's a trauma hospital, you're going to go there. If it's a gunshot wound, you're going to go there. If it's cardiology, you're going to go there. More than likely, your preferred hospital—think Cedar's Sinai, Mayo Clinic, Langone Medical Center—if those are your preferences, let's get those out front so you know that is where you can go to have your procedures done and stay with your favorite doctors. That should be right on the table.

If your agent isn't getting that information out and problem-solving around that for you, find a different agent. You're probably dealing with a sales agent that just wants to get your money and doesn't really care about you in the long term. So again, pick an agent who's been around for a long time. A broker represents five or more companies; they're going to do a needs analysis and then they're going to make a recommendation for five or more policies. Some of you might like them, some of you might not like them, they might be too expensive. Well then, you're going to work it down to what's reasonable. Alright?

Answer: What a great question! Will Medicare Advantage plans start offering more digital health tool apps by 2030? Well, of course, we're in the world of artificial intelligence here. If we can gather data by using watches, phones, or apps that can capture, you know, atrial fibrillation, for example, this is going to be the next wave of being able to capture data in real time, and it's terribly exciting.

This whole Aura ring, or the app on your phone, or the smartwatch being able to be used as a detection device for atrial fibrillation, for example, is really important. A-fib comes and goes over the course of the day. You wear a Holter monitor for 24 hours, and you may have no A-fib, and that doesn't mean that you don't have A-fib. Right? You get rear-ended in a car accident, or you have somebody swerve at you or swear at you, and that's going to bring on your A-fib. Unfortunately, when you're walking around with a Holter monitor on, you're probably not going to be getting into that little skirmish.

So absolutely, we're already seeing changes. Think back before COVID—like, hello, virtual visits weren't even an option then, and now we have those coming out the wazoo, bringing the cost of care down. This allows doctors to spend more time with really sick people. Redundant visits can be put through the virtual system, and necessary face-to-face visits can be used in the necessary face-to-face sphere. Yes, there's more to come!

Answer: The best way to avoid surprise bills for lab tests under Medicare Advantage is to ask your provider if this is a standardized test and if it’s medically necessary. For example, some people find out their vitamin D deficiency or whatever it is often isn't covered, or some hormone panels or other elements of blood work can lead to surprises. So, ask your provider if this is part of a standardized panel and if you will be charged extra for that. The doctor should know.

If you have any further questions, I would suggest contacting the Medicare Advantage company to make sure that it will be covered. If not, then what's the cost-benefit analysis of you paying for that test versus not having the information? The doctor can tell you that. If he really wants the information, he’s either gonna have to make a way for Medicare Advantage to pay for it or advise you that you're going to have to pay for it.

Answer: How can I select the right healthcare company and representative to work with? I would say, first of all, find somebody who represents more than one company. Otherwise, you're dealing with a sales agent, and that's it. The person's job is to sell you a policy from that insurance company, whether it's United Healthcare, HealthNet, Humana, SCAN, Alignment, Aetna, CVS, or whoever. Their job is to sell you, regardless of your needs. How many of these people are gonna say, "You know what? I represent Joe Blow Medicare Company, and I don't think you need to be with us"? They're not gonna tell you that.

So, find a broker that represents at least five to seven companies. Those five to seven companies should probably have 50 or 60 different plans, including Medicare supplemental policies. Have them take you through the discipline of a needs analysis. Then, you'll know what your needs are, and you can match up policies that go along with those needs.

We've all had lots of shocking information this last year about United Healthcare and terrible things that are happening, leaving people angry. I don't want that for you. One way you can find out if your insurance company, per se Medicare Advantage company, is gonna be difficult to deal with is by looking at star ratings. A star rating of 4.5 or above is more than likely gonna lead to a fairly good fit for most people's needs in terms of accessibility, available resources, affordability, infection rates, mortality rates, etc.

So, use the star ratings. Although they're a looking-backwards perspective, if they've been successful the last ten years, then they're probably gonna continue to be. Run away from companies that have a 2.5 or a 3.0 star rating because they haven't even met the metrics that Medicare requires of them to keep their plan in action.

So, there's a few things to guide you. Find somebody like me who can assist you in navigating your needs. Look for five or six companies that they represent, do the field work, and you'll be happy. And guess what? You can change next year if you need to.

Answer: This is a bit of a wrenching question. I'm caring for my spouse with dementia and experiencing caregiver burnout, which is very real, by the way. The question is, will Medicare cover any mental health support for me?

Well, if you are on Medicare, if you have a Medicare policy, yes, mental health is covered under Medicare. Caregiver support is referred to as respite care, and almost all of the Medicare Advantage policies, if that's what your husband is in, include respite care. It's not a lot, though; it's not nearly what it needs to be. It's for approximately one week per year that you will get respite care for your husband.

This is a very difficult part of placing the burden of care on the spouses and children of the Medicare beneficiary, and something that has to be planned for, or else we fall into this circumstance. I'm deeply concerned for families under these circumstances, especially families that are isolated, because they can be making decisions that may not be in the best interest of anyone.

So, if you are in a Medicare Advantage policy and you find yourself in this circumstance where you're caring for a Medicare beneficiary, get with your Medicare Advantage policy. Get with them, get to a case manager, explain the circumstances, be clear about your burnout, and ask for case management assistance, not only through the plan but through the state as well if there's anything there. That is definitely the first place to start.

Now, if you have children that are 40 years old and they're watching you go through this, I want you to have a conversation with them and have them reach out to somebody who can assist them to prevent the circumstances that you're currently in. That way, when they get aged and if they become infirm and need care in their home, they have a policy for that. There are many of them around, but they're not affordable if you try to get them when you're in your 60s and 70s, not at all. You gotta do it when you're in your 40s or 50s, and at that point, it's brilliant, brilliant, brilliant. Everybody wins. You can do those as part of a life insurance policy or as a standalone critical illness policy.

Answer: Yay, an easy question! Does Medicare Part A cover outpatient surgery, or is that strictly under Part B? Outpatient surgery means that it is not in the hospital, so it should be under your Part B. Simple and straightforward, especially if it's an outpatient facility not being done in a hospital. So there you go!

Answer: So this question is about drug plans. I've been on a drug plan for a while and I'm wondering why my generic prescriptions suddenly cost more. Did something change? Heck yeah! January 1st this year changed, which really, if you didn't make a drug plan change or you didn't do an analysis in the algorithm to see how much your medications would be costing you, everything changed. The plans went up in price, some of them went down lower, and most of them have a $590 deductible on all of the tiers. There is a max out of pocket of $2,000 a year, which is kind of nice, and there's no longer a donut hole. So yeah, if you've had the same drug plan, yes, the structure of it is very, very different. It's got this big deductible of $590 that you've got to pay for your generics through unless you're paying $150 or more for a policy in California. I'm sort of using a generalization here, but this is the way they've clustered. No deductible at the cheap end or at the expensive end, so if it's over $100, typically there's no deductible. Under $100, typically there's a $590, generally speaking.

So the other thing, that's one answer: the structure of the drug plans has changed as of the 1st of January 2025. I don't know what it's gonna look like next year. We've had this administrative change, we don't know. So that'll be interesting to find out. You may want to reach out to a specialist who can help you do the analysis during the annual election period.

So the other thing that's kind of tricky, and I get people calling me about this quite regularly, I like to use the case of Wellbutrin, which is a very mild antidepressant. It's also used for L4 subluxation pain management just as a receptor number for that area in the brain, and people have been using it for years. It's been out since the 70s, but there's now this extended release version of it which puts it into a tier 3, and the doctors aren't telling patients when they switch them from their 300 milligram Wellbutrin to a 300 Wellbutrin XR, the extended release. That's a tier 3. That's a completely different animal. So when those kind of surprises come up, I would be inclined to either contact your agent and have them help you figure it out or backtrack on it a little bit and see if in fact the formulary hasn't changed or the formulation of your drug hasn't changed. So that's a sneaky one.

Answer: If you're traveling out of the country for a period of time, I'm sure you're concerned about what Medicare will and will not cover. Generally speaking, individuals need to have some kind of coverage up to the first $50,000 so that you can be stabilized and then brought home. How you get that coverage is in a variety of ways. For example, a few Medicare Advantage policies will include travel coverage. If you just call them up and say you're leaving from October 15th to January 1st, they'll send you back in the mail a copy of a travel policy, which is very cool.

If you went to GeoBlue, for example, at age 66 and wanted to buy a three-month travel policy, that might cost you three or four hundred dollars for $50,000. So, you know, that's pretty valuable. The other way that people will get coverage while they're away is through some of the Medigap policies. The G policies have international travel built into them, which is very cool. They typically pay for the first $50,000 until you get home, and you're obviously paying more for that policy because it has that nice little built-in benefit, unlike other G policies that don't have that. So, your G policy is going to be expensive.

The other thing that my clients do is they will buy before they turn 65 because of California accident policies. If they're in Hawaii and have a few too many Mai Tais and trip over something, they end up in urgent care or the ER. They have an accident policy that's very, very cheap. If they're admitted and stay overnight, they can just file a claim and get a check for two grand. Those policies are great, they're just pennies, and they work for the rest of your life.

So, if you're a smart cookie, before the age of 65, ask some questions of an agent like me who looks at it from the big picture. We will recommend an accident policy because they happen, they're inexpensive, and they pay you thousands of dollars, not just to the people that are billing on your behalf. They pay you cash, so it's a very cool thing. Check it out!

Answer: Ooh, I love this question! Why do so many seniors wait until the last minute to enroll in Medicare, and how can agents help prevent bad decisions? Well, I think I mentioned in another video that people just space it out. They kind of go to Mexico, leave the country, move, play with their grandchildren, or just enjoy their life. I've even had one client who forgot she was 66, and that was terrible.

So actually, after her, what I've done now is call my clients that are turning 65. Typically, I'll call them when they're 64 and say, "Hey, next year you're turning 65, and guess what? We get to save lots of money!" I put them in my calendar to follow up. That's what I do to protect my clients, and that's why people typically enjoy working with me—unless they meet somebody they like better or their brother-in-law becomes a sales agent or something like that. But even at that, it's hard to beat somebody who's been doing this for 10 years with CFP credentials and an MBA.

So, how can agents help prevent bad decisions? Well, work with them well before they turn 65 so they can do the budgeting and plan for things like cataracts or knee replacements. Get people excited about the benefits of Medicare, 'cause it's either way less expensive than what they're paying, or they have access to thousands of doctors for hardly any money with a Medigap policy. This is the one time that getting old is actually kind of exciting!

I get excited for my clients because they've been putting off colonoscopies, mammograms, or pain management. They've been putting it off because they've had problems. So when people come and see me, just like most other seasoned agents and brokers, we encourage them to plan. This is exciting! They get to finally deal with things without a managed care plan getting in the way.

You know, develop a strategy that can be pivoted. I pivot my clients almost every year because their needs change. I invite my clients to come back as often as they need. So, get a relationship with somebody that you know and trust, and who isn't all serious and salesy about this stuff. That's my suggestion. Alright!

Answer: Great question! I'm worried about choosing the wrong plan and being stuck with it. How often can I change my Medicare coverage? I'll answer this in two ways. First, there's basically several ways that you can do it. Number one, you can do it during the Annual Election Period, which is October 15th to December 7th. If you don't make a change during that time, you can make a change from January 1st until March 31st. Those are the two general times that you can make changes.

There's also something called Special Election Periods. This means that if your plan goes bankrupt, that would be another time you could change. If you move out of the state or out of your service area, you can then make another change. Or if you have a change in your health conditions, for example, if you have COPD or some big change happens to your health situation, you can change plans if there's one available in your area.

So, to answer your question, you can change it during the Annual Election Period in the fall or in the spring, or when you have a change in circumstances.

Now, about your concern of choosing the wrong plan—I'm worried about that for you too. What I've observed over the years is that people like to go to meetings where they get cookies or some squishy balls, or they sit in an audience and a sales agent sells them a plan. They tell you all the wonderful things it's going to do for you and how it's going to save you money, but they don't tell you about the doctors. They don't tell you about the network or if your doctor is in-network. Often, after you get into that plan, the network changes.

If you're only talking to one person who's a sales agent incentivized to sell you into that one plan, then you're more than likely going to be deceived. Again, I suggest you work with a broker.

Answer: No. HSA cannot be used for premiums. Just copays and out of pockets for anything medically related.

Dental, vision, glasses, hearing aids, out of network providers, experimental drugs.

Answer: This is a really interesting question to be looking at in 2025. From my perspective, the question is, is Medicare Part A enough for hospital coverage? Today, we would say no, but if we were asking that question in 1950, people would be saying, "Oh my gosh, that's wonderful that Medicare Part A covers 80% of hospitalization." It wasn't that long ago, honestly, that men walked on the moon and there was no such thing as Medicare. People had to pay, and many went bankrupt. People still go bankrupt for different reasons, but we have Medicare Part A, which is free for many people. That's what they have to have if they have Medicaid. If they're low income and can't afford a supplemental policy, then Medicaid pays the balance. So yes, it can actually be enough, but that's not true for everyone and not all the time. Generally speaking, no, we need a supplemental policy because 20% of an unknown number can potentially be extremely high. For example, going to a doctor's office, a 20% copay could be only $40. But going to a hospital, a 20% coinsurance on $1 million could be $200,000 or more. So it's a necessary thing. We need to look at it and find a way to affordably make that happen for everyone. But thank goodness we have Medicare Part A that's free. We are so blessed.

Answer: This is a great question. Charise Karjala with Health Markets Insurance from my office in Palm Desert, California. The question is, what is one piece of advice you wish every senior knew before picking a Medicare plan? My answer to that is, to thine own self be true. This is a time where we need to have an objective look at what our needs are, and some of us don't have very accurate mirrors. I wish every senior, upon entering Medicare and then doing their semi-annual reviews, had an opportunity to speak to a professional who would ask them my 12 points of questions, which are very particular. I wish that every senior had a chance to sit with somebody who understood the system and could ask the pointed questions so they could know themselves, their own needs, and preferences in advance.

We have a three-tier system of Medicare, and each system is very different. What is good for this goose may not be good for this gander, which may not be good for the other one. The level and quality of care between those three different systems diverge greatly. So yes, I would say know thyself, know what you're up against, and find help to thine own self be true. Helping people will assist you in understanding what you are looking at from yourself and how to match that up with the available options. There you go.

Answer: Hi, Charise Karjala, Health Markets Insurance Agency, in my office in Palm Desert, California. This question is one that is heartwarming for me because it's one part of Medicare that, when we really need it, it's there in spades. The question is, if I need hospice care in the future, can my Medicare plan cover it? And it's a resounding yes. All hospice care is covered by Medicare at 100%. End-of-life care is something that we all deserve—compassionate and stress-free care. I'm so proud to be part of a system that supports end-of-life care, compassionate care in a way that is kind and gentle, and really lets individual caregivers shine in their compassion and loving attention to people in their final stages. So, thank goodness, yes, we do have Medicare plans that cover it. Thank you for the question.

Answer: This is a nationwide question, and it reads: "I chose original Medicare to keep my doctors, but now I'm drowning in bills. Should I have gone with Advantage instead?" Well, what kind of bills are you drowning in? Is it that your premium for your supplemental policy has gone up? That's a fixed amount, so there shouldn't be a flood of those bills coming in unless you have something other than a G policy. With anything other than a G policy, you can end up with some very significant copays, coinsurance, and overage charges by physicians that don't accept Medicare as full and complete payment. The G policy is the only one that will pay for new Medicare beneficiaries. Obviously, if you aged in before 2020, you would have the F, which is the fabulous plan, but even at that, most of those F plans have gone into G for grades because, as a cost measure, the G is more efficient.

So, back to the question: Should you have gone with an Advantage plan instead? You could have done the research with your Advantage plan and determined that none of your doctors were included in that. The decision you made at that time would have been to keep your doctors. I think the concern here is perhaps you were ill-advised on your gap policy that you procured when you aged in or switched into after purchasing a Medicare policy. There's a lot of bad advice out there, and I want everyone to hear this lesson: Find a broker. Find somebody who's been doing this in your community for a long time or someone who has enough wits about them to understand the bigger picture and is willing to take an hour of their time to do a thorough needs analysis, because that's what needs to happen. We can't go backwards; we can only go forwards. So, gap people, use your birthday rule, find a good agent, and do a policy review. All right, take that one.

Answer: This question is, how does life insurance contribute to financial planning? Well, there are probably 40 ways that life insurance policies contribute to financial planning, but I’m gonna limit my response to how it relates to Medicare beneficiaries who have shortcomings in their Medicare policies or their health coverage that precludes them from having coverage for long-term care, either inside the home or outside of the home in a facility.

$341,000 is the number that people aging into Medicare today in 2025 can reasonably expect to spend on Medicare-aged benefits that aren't covered by Medicare, and long-term care being one of those. There are several other ones, and so myself and my colleagues will always recommend some kind of critical illness policy before they turn 65. This policy will allow them to have a lump sum benefit in the event of a debilitating illness where they need round-the-clock care.

Those critical illness policies can be portions of life insurance policies, which is exactly what else I do, because it’s very important. You can’t get that money back when you’re 80 or 90 years old. You’re depleting your scarce resources, and your poor children are shaking in their boots, 'cause there’s nothing left. They lose you, and they lose all the money too, and it’s dreadful for those of us who have been through it. You know what I’m talking about. It’s just an unfortunate circumstance.

So yes, life insurance contributes to financial planning under Medicare in so far as the life insurance includes critical illness or long-term care benefits. These benefits need to be planned for, usually by people in their forties.

Answer: This is a great question. What's one Medicare decision that too many people regret later? Universally, the one decision that people make is not to decide. They forget that they turned 65, or they've been living in Mexico, or they were distracted, or they were doing something else. Not enrolling in Medicare during the initial enrollment period creates obstacles that are very difficult to unwind later on.

For example, if you forget that you're 65 and your birthday is in May, then the following May comes around and you're thinking, "Oh my god, I'm 66. I didn't enroll in Medicare and I haven't had any insurance." You're going to have a permanent late enrollment penalty for quite a bit of money because guess what? It's May, and you can't enroll in Medicare until January, February, or March, usually for a July 1st enrollment. Unless, of course, you had an employer-sponsored plan, then you've got a gimme. But for people that are just spaced out, they will face hundreds and hundreds of dollars in costs associated with not knowing what their birthday is and what their requirements are.

Most of my clients hit me up because they're really scared of that. That's my answer to that question. The second item that individuals regret is just picking any old plan. For example, you know, I'm gonna use Kaiser or HealthNet. My mom had HealthNet; she liked it. But without going through the discipline of seeing if there are actually any providers in your community under that carrier, you might run into issues. I just use those as examples because they've come up in my community as not having solid and extensive specialists.

So I think those are the two main regrets: just not being careful about enrolling in a Medicare Advantage policy and not doing the research on your area. And for crying out loud, just enroll on your 65th birthday. Just get it done, you know?

Answer: Hi, good evening. Charise Karjala with Health Markets Insurance Agency in my office in Palm Desert, California. This is sort of a nationwide question because it applies to Medigap policies, which are nationally administered and standardized.

So the question is, can I change my supplemental or Medigap plan at any time? The quick answer to that is yes and no. The birthday rule is the one that applies to the month of your birthday, where you can change your plan without going through underwriting. Generally speaking, that's the safest assumption to make. You, as a consumer, should plan to do a review each year with your agent or with the carrier, or shop it amongst the carriers to make sure you’ve got the best pricing. That’s just a matter of discipline.

I don’t know about you, but in the year 2024 to 2025, we’ve seen some pretty substantial price increases in the Medigap policies. So I have lots of people right now who are shopping their Medicare policies, and they understand that the birthday rule is the time to shop their policy, where they can freely go between carriers. Within carriers, they will allow you at times to move down, so for example, from an F to a G, or a G to an N, or an N to an L, but not necessarily move up unless it’s a birthday period.

The other option, if you want to switch a carrier in the middle of the year, is that more than likely you’ll need to go through medical underwriting, which for some people is easy peasy, no problem, but for others, it’s daunting.

So, rule of thumb: can I change it at any time? Yes, but do it during your birthday month, or you risk having to go through underwriting and not getting the advantage of being able to do your cost savings. Just make sure you’ve got a good agent or somebody on your side who’s shopping your plan each birthday. Just ask them to run the prices, or use an agent broker like me. I’ll leave that one with you for now, and keep the questions coming!

Answer: Charise Karjala here with Health Markets Insurance from my office in Palm Desert, California, responding to the following question: How do Medicare Advantage star ratings affect the quality of care I can expect? Interesting question. It's kind of two-part. How do Medicare Advantage star ratings come to be? That should be part of the question. Then, secondarily, how can those rear-view mirror perspectives of the performance of the Medicare Advantage plan affect the quality of care that I can expect? Those are two distinct elements.

So, number one, how do the star ratings come about? Well, annually, Medicare Advantage plans are audited on the basis of many important variables, including how happy people are with it. But more importantly, infection rates, readmission rates, compliance, the degree to which seniors are participating in their prevention of care, mortality rates—there's a bunch of variables involved in this. But that's all a year, a year and a half ago, so that data is old. The star ratings that will be released at the end of 2025 will be from last year.

So, can last year's information affect how well you're gonna be cared for next year? I'm not sure. But what I can say is that if a plan has a star rating of three, they're probably gonna lose their plan enrollment ability because they're penalized. They have expectations from Medicare to meet a minimum standard, and once they start to not be able to meet those standards, it's just a snowball. So, it makes it difficult for the plans in the future to continue to meet the expectations. When you've got a 4 or 4.5, you've got a plan that has consistently delivered on the minimum requirements as of last year.

So, another element would be to ask how long the plan has had a 4.5 or a 4.0 star rating. The consistency is important to look at.

Answer: Good evening, this is Charise Karjala with Health Markets Insurance Agency at my office in Palm Desert, California. This question reads, "Will Medicare cover everything my current employer plan does?" That's a great question, and it's pretty hard to answer without knowing how old you are, what your Medicare eligibility is, and what your options are within your finances.

But I will say this: employer-sponsored plans or individually family plans have carve-outs or additional benefits that may be different from Medicare's. In the case of some employer-sponsored plans, I think of Starbucks, for example. They have cut coverage for certain procedures that insurance companies and Medicare do not approve of, and it's considered to be an employee benefit. So think in vitro fertilization or some LGBT procedures. Those are two that would be covered but aren't really appropriate for Medicare beneficiaries, if you know what I mean.

So let me say this: Medicare, at the end of the day, if you have Medicare as a secondary, which is a gap policy, there's no insurance company between you and Medicare. There's only you and the CMS regulations and Medicare to administer them. As long as your doctor is doing the diagnostics and the coding correctly, there's no insurance company to say prior authorization or not approved or needs a second opinion or a flat no. If it's approved by CMS, the markers are all hit, you've got the appropriate protocol, then there's no reason for it to be denied.

So the question, "Will Medicare cover everything my current employer plan does?" Yes, and maybe more easily. So think about that one.

Answer: Thank you for the question. My name is Charise Karjala, and I'm a broker in Palm Desert, California. The question is, I'm living solely on Social Security of $1,400 per month and can't afford my Medicare premiums and copays. What assistance programs might help someone in my situation?

Well, $1,400 is well below the Medicaid threshold, so that would be the first line of offense: contact your local Health and Human Services office and apply for Medicaid for your state. That will eliminate your Medicare premium of $185. You will then be eligible for a dual eligible policy, which means you’ll have both Medicaid and Medicare. In my state, it's called Medi-Cal, but it's Medicaid.

So, that's number one: just do that. Does everybody do that? No. I have some clients who have trust funds that support them, so they may have $1,400 a month in income, but they have trust fund money that pays for their health coverage. It doesn't sound like that's your option in this circumstance.

Once you become dual eligible for Medicaid and Medicare, you have a special election period every single month, at least in 2025, to change your policy. As soon as you get dual eligibility, you can go into a zero premium, zero copay, zero Medicare Part B premium policy. But you've got to hit up your Health and Human Services office in your state.

Answer: The question is, I picked a Medicare Advantage plan based on the low premium, but now I'm facing high copays. Did I make a mistake? Buyer's remorse, right? I don't know. Honestly, if your primary objective was to have a low premium or a zero premium, then perhaps that's fine. If you were tricked into getting a policy based on a low premium and now you have high copays, that's unfortunate. This is part of the challenge of having Medicare agents going out and selling in a community and only representing one product.

Compare that to people like me. We're brokers, and we work for multiple carriers. We have the opportunity to do a needs analysis, which involves 12 variables. Then I can go through my available products, which are around 75, and make a recommendation for maybe three or four that would meet your needs. That's why you want to work with a broker and avoid going to the selling events. They can be kind of fun if you're going with your friends and having coffee, but if you want a very good fit and no buyer's remorse, contact an agent who has access to lots of different carriers.

We are called brokers. There are two things I want to tell you, and I'm not sure if I'm going to have enough time. Number one, the Medicare Advantage annual election period is stated as being from October to December. I want you to know that there's also an open enrollment from January until March 31st, which is a much quieter and saner period to be making changes. So I invite you to take the pressure off and contact one of the wonderful agents through this hub. Ask them who they represent and be satisfied that you're not being sold, so you won't have buyer's remorse.

Answer: Charise Karjala here from Palm Springs, California. The question is, isn't it concerning that Medicare Advantage plans are taking over the system? It's an interesting question, and I'm gonna tackle it in a couple of different ways.

Number one, I'm gonna refute that they are taking over the system. There are many, many people who do not want to have Medicare Advantage, poor and rich people alike. They opt to spend their resources where they choose. If they choose to have a Medicare or a Medigap policy and a drug plan, that's their choice, and they put their money where their preferences are.

Medicare Advantage is a system of affordable care that provides embedded benefits over and above Medicare CMS guidelines. They do all of the care stuff that gets done, and they throw in benefits like dental, vision, rides, over-the-counter items, food, and it goes on and on—hearing aids, and yeah, it's wonderful. Medicare Advantage policies cost our country far less than Medicare policies do, and in so doing, they save us taxpayers money and also save the consumer money. The consumer pays for a Medicare Advantage plan, their Medicare Part B premium, whatever that is, which fluctuates, and then they pay basically nothing else other than some copays, up to a maximum out-of-pocket of around $1,000 a year. It's brilliant. What's the matter with that?

Well, what's the matter with that is what are you giving up to get access to that affordability? Where I see the problem with Medicare Advantage is that the transparency of the network compromises the plans that are being made on an annualized basis. There is value in working with a broker who understands the complexities of the networks in any given community, especially ones that they live and work in. The consumer does not have the benefit of understanding the size and the ability to access different providers within their network. This is a major drawback of the Medicare Advantage policies. I hate to hear of my clients waiting months for a referral because this stuff not only should not be happening in Medicare Advantage.

So there's your answer: Are they taking over the system? No.

Answer: The question as asked is, what is the difference between a Medicare broker and a Medicare agent? Let me start by giving you the background on agents. Agents are licensed through the state, in this case, California. One needs to have a grade 12 education and not have a felony or a misdemeanor, so the standards are fairly low for agents. Typically, agents will work for a carrier such as Humana or Molina, and they represent typically one line of business, although that may not always be the case.

Health Markets, the agency that I work for, hires Medicare agents only after they have proven themselves in the world of health insurance for at least one year. The reason for that is that Medicare can be legally, morally, and financially disastrous for our seniors if it's done wrong. So the idea is that Health Markets thoroughly vets their agents. Even if they are only representing one carrier, they are at least protecting the consumers.

So that's the definition of an agent. A broker, unlike some other businesses, does not take possession of whatever it is that we're selling. What we do is we are contracted with multiple carriers, and many of these carriers are very difficult to get contracted with unless the individual agent who acts as a broker is very seasoned, has a strong reputation, and a good book of business with a long background.

When you find a broker such as myself, Charise Karjala, I've got years of experience in this business. I represent multiple carriers at any one time, and these carriers are ones that I know and trust. In doing so, I only recommend the carriers that align with my reputation and background. I only represent the ones that serve my clients well.

Answer: This is in response to the question of whether Medicare pays for medical marijuana for pain during chemotherapy, and the flat-out answer is no. Medicare, as of 2025, will pay for nausea and the side effects, but not for pain. So if you want to use THC or cannabinoids for pain management, I think we all know where to find a dispensary, and your oncologist or prescribing physician will prescribe you the CMS-approved prescriptions for pain management. Unfortunately, some people want that, but at this point, we have to privately purchase it, and we all know where we can get that from. Thank you for the question, and keep asking.

Answer: Thank you for the question regarding wheelchairs. The question is: what's the deal with Medicare and getting wheelchairs? So, here's the specific answer. Wheelchairs are categorized as durable medical equipment, and they have to be ordered by prescription. That means a doctor has to write a prescription for a piece of durable medical equipment. It’s in the same category as prosthetics, orthotics, and artificial limbs. It seems a bit overkill, but it's just a CMS rule. Medicare has that category of product, so wheelchairs, walkers, and that kind of thing are all under durable medical equipment and they're available by prescription. It seems kind of ridiculous to have to go through all of that for a $200 wheelchair, so as a result, most people just go out and buy them. However, bear in mind that the wheelchair you're getting is also in the same cluster as wheelchairs for people who have, for example, quadriplegia. It's an unfortunate way that the system codes it, but just be aware that typically durable medical equipment has a 20% co-insurance with your Medicare Advantage policy. Yeah, you do have to have a prescription or you can go out and buy it yourself. Hope that helps. Have a great day.

Answer: How Medicare Part D covers expensive medications:

Formulary:

Each Part D plan has a formulary (list of covered drugs) organized into tiers (generic, preferred brand, non-preferred brand, specialty drugs, etc.).

Expensive medications are usually placed in the specialty tier, which often has higher cost-sharing (a percentage, not a flat copay).

Cost Stages During the Year:

Part D plans have four payment stages each year:

Deductible Stage:

You pay 100% of your drug costs until you meet the deductible (maximum $545 in 2024; this may be slightly different in 2025).

Initial Coverage Stage:

After meeting the deductible, you pay a copay or coinsurance (often 25%) until total drug costs reach a certain amount (around $5,030 in 2024).

Answer: If you are on SSDI (Social Security Disability Insurance):

SSDI is an insurance program you earn by working and paying Social Security taxes.

When you reach full retirement age (currently 66–67, depending on your birth year), your SSDI automatically converts to Social Security retirement benefits.

You don't need to do anything — the switch happens automatically.

The amount of your monthly check usually stays exactly the same — it just becomes classified as "retirement" instead of "disability."

This change can sometimes affect things like work incentives or how other benefits are calculated, but it does not reduce your payment.

Answer: Charise Karjala educates clients who are new to Medicare by breaking down the complex system into clear, manageable parts. She starts by explaining the basics: what Medicare is, who qualifies, and the differences between Original Medicare (Parts A and B), Medicare Advantage (Part C), Prescription Drug Plans (Part D), and Medicare Supplement Insurance (Medigap).

Charise uses easy-to-understand language, avoiding heavy jargon, and encourages questions throughout the process. She often provides visual aids, handouts, or personalized summaries to help clients compare their options side-by-side. She walks clients through timelines—like when they need to enroll to avoid penalties—and helps them assess their personal healthcare needs and budgets to determine the most suitable plan.

Charise also stays patient and empathetic, recognizing that Medicare can feel overwhelming, especially for those transitioning from employer coverage or the individual market. She offers both in-person and virtual meetings, giving clients flexible ways to learn at their own pace. Her goal is to ensure clients feel informed, confident, and empowered to make decisions that best support their health and financial well-being.

Answer: Medica policies are very different from one another. You probably came up short with your needs analysis or listen to a friend who suggested their ““ Best” policy.

A careful needs analysis and consideration for finances is the most appropriate way to determine which policy is “best” for you.

If you’d like assistance with this analysis, please contact me for a free consultation

Answer: I use an algorithm to determine if the Medicare supplement policy is appropriate for my given client.

If you’d like additional assistance with this reliable method of determining whether a Medicare supplemental policy appropriate, please contact me. Charise Karjala

Answer: Sounds like you’re in a Medicare advantage policy. Each Medicare advantage policy has different co-pays and some of them have $300 co-pays for Ambulance.

The summary of all of the co-pays is included in the evidence of coverage you received when you signed up. You may want to refer to that just to confirm.

If it is not outlined specifically in your evidence of coverage as being $300, then contact the carrier and dispute the charge.

That’s your right.

Answer: Fear. Resistance comes from fear.

Fear of making the wrong decision; fear of unknown; fear of the system; fear of being victimized by insurance companies.

Fear of bad advice is the common theme here. Agents and Brokers are not a homogenous bunch -- there are people with only a little knowledge of one or two companies in the same category of 'agent' as those with decades of experience, advanced designations in underwriting and financial planning and inside industry knowledge. From the outside looking in, these agents all kind of look the same.

I suggest to consumers to ask these questions to determine if your prospective 'agent' is worth listening to:

What year did you start representing medicare products

How many carriers do you broker for.

Can I check your insurance license number.

What training and industry experience do you have.

What is the most difficult client you have taken on.

What is your website and review information.

Responses to these conversation openers will inform the consumer of the depth, breadth and capacity of the agent to be reliable and accurate.

Once these clarifying background questions are answered, the consumer generally has a greater ease in trusting the advice of the agent.

Answer: Yes absolutely. There's no need to use COBRA. You can activate your part B premiums if you are over 65 and then be in a plan very quickly. Please don't overspend on COBRA, except under certain circumstances.

Answer: Call 1800 Medicare for assistance. Provide them with the information and your questions will be reviewed under compliance.

Answer: Typically, Social Security will send out your Medicare Benefits card 3 months prior to your 65th birthday month.

You may also be eligible for Medicaid, which makes things a little more complicated in accessing different plans, or you may involuntarily be enrolled in a plan without your knowledge.

Get with a competent Medicare broker (non a salesperson); they can do a thorough needs and situation analysis and assist you to understand your options and develop a winning healthcare strategy.

Answer: I have a seven question algorythm that is 99% accurate. Seven questions and the appropriate strategy is evident.

Answer: Your part A benefits are for hospitalization. Your medi-Gap policy should cover the majority of the patient coinsurance; or you Medicare Advantage policy will cover it per your explanation of benefits.

Please find a Medicare agent to assist with your needs analysis and policy description so you can rest easy without worry about the what -ifs.

Answer: A present, my most pervasive challenge is navigating the dual eligible market. That means for people who are either aging in or have Medicare and Medicaid.

This market is always particularly challenging in my area because the networks are constantly shifting. Medicaid is going under massive changes and there’s a lot of uncertainty with the Provider networks. In addition, those networks are very busy and flooded with patients. So I’m consistently challenged to make sure that I have the most timeline and relevant information

Answer: Granular market specific information is only available through a specialist that works in your community. Meeting face-to-face with your agent is an important way to assure yourself that you were getting specific, relevant, verified and accurate information regarding your network of hospitals, doctors, facilities, and prescription drug delivery systems

Furthermore, your agent can get to know you, personally, and thereby understand your needs more thoroughly than a phone call or a Zoom call.