Diana Garner, Medicare Insurance Broker

Answer: Navigating the world of Medicare is challenging. Enrolling can be difficult, but with guidance, it becomes easier. Working with a Medicare agent can be beneficial because they can help you navigate the complexities of Medicare, compare plans, and find the coverage that best suits your needs and budget, saving you time and effort.

Being knowledgeable about the different types of Medicare plans allows us to be prepared to explain the benefits, coverage, & cost of each one. By assessing your individual health needs, medications, and budget, we can recommend the most suitable plan.

Answer: Most Medicare Advantage plans are offered as zero-premium plans, but there are a few plans that do have a monthly premium. They can not be truly considered "free" because other costs are associated, such as your Medicare Part B Premium, and you may incur possible deductibles, copays, and coinsurance when seeking medical care up to a defined max-out-of-pocket amount.

Even with that being said, there are low-cost plans called Hospital Indemnity plans that can be purchased to help combat those out-of-pocket expenses.

Answer: The maximum out-of-pocket, also referred to as MOOP, is a limit on the amount of money you are responsible for paying when receiving covered medical services in a plan year. Once the limit is met, your plan will cover 100% of your covered health care costs for the remainder of the plan year.

The MOOP resets each year and is subject to change. All Medicare Advantage plans must set an annual limit on your out-of-pocket costs.

Answer: I wouldn't say Medicare allows it; however, private insurers aggressively market Medicare Advantage plans to gain enrollment and sometimes use tactics that can be confusing.

Some ads or mailings can be misleading, such as promising benefits at a specified amount that isn't correct.

Medicare beneficiaries are more vulnerable. That's why I recommend working with a broker you trust to handle your insurance needs. I tell all of my clients to call me with any questions they have about anything they see on TV or receive in the mail. This is my way of protecting them from being enrolled in a plan that isn't a good fit for their situation.

Most of the time, the people on the phone you reach to go over your benefits, don't discuss all aspect of your needs such as medications, doctors, etc.

Answer: Some Medicare Advantage plans still have referral requirements. It is always a good idea to carefully review the plan documents to see if referrals are required.

Answer: The notice you receive from Medicare, which includes details on why home health care was denied, will also include information regarding your appeal rights and the steps to take.

First, you must file an internal appeal (redetermination) with the Medicare Administrative Contractor, which involves submitting a request form with supporting documents.

If the Medicare Administrative Contractor denies your coverage after reviewing, you may request reconsideration by a Qualified Independent Contractor.

If denied again, you can request an Administrative Law Judge hearing. This involves a formal hearing in front of the Judge, and you will present evidence and argue your case.

If the Judge denies your claim, you can appeal to the Medicare Appeals Council.

If you are still unsatisfied, you may have the right to seek judicial review in the Federal District Court.

Answer: Medicare provides some support to help beneficiaries who are trying to quit.

Medicare Part B covers a variety of preventive services, and smoking cessation counseling is included.

Medicare Part D (prescription drug) plans may cover prescription medications or nicotine inhalers and nasal sprays that require a prescription.

Answer: The biggest red flag is when the caller asks for your personal information. Legit Medicare reps will never call you unexpectedly and ask for your info, such as Medicare or Social Security number.

Scammers may:

1) pressure you to act right away

2) claim there are new or better benefits available then ask for your Medicare number

3) promise free or discounted services in exchange for your info

4) offer large refunds or rebates

I make it a point to tell my clients to be cautious when answering the phone, and if they do get a call about new benefits, they need to tell the caller, "I need to speak to my broker and confirm with them". Most of the time, the caller will either hang up or pressure them more but they call me and I can review what they were being told. Most of the time I have found the information they were given was inaccurate.

Answer: Generic drugs in tier 1 and tier 2 are generally still $0 co-pay as long as your medications are on the plan's formulary. High-tier medications have co-pays up to the max out-of-pocket of $2,000. The highest medications are newly introduced medications or specialty medications.

Most Part D (prescription drug) plans now have a higher monthly premium and a deductible, where before there were a few with $0 to low premiums and a $0 to low deductible.

In the United States, we do not have a price negotiation system. This allows the drug manufacturers to set prices. We also don't use value-based pricing, where drug prices are determined by the value they offer to patients, leading to potentially overpriced drugs.

Answer: Even with the coverage gap being eliminated and a max of $2000 out-of-pocket being set, medications can still be costly.

Medicare Beneficiaries can:

1) Apply for the Low-income Subsidy (extra help) through Social Security

2) Apply for the state-based program called the Medicare Savings Program

3) Apply for patient assistance programs offered by the drug manufacturers or non-profit organizations.

Answer: If you are still surprised by the bills you receive, that tells me two things:

1) You are more than likely on a Medicare Advantage plan

2) Whoever you are working with to sign up isn't explaining your benefits, copays, coinsurance, or deductibles clearly.

To ensure you fully understand the plan you choose to enroll in, it is best to work with someone who will explain everything to you.

If you are on a Medicare Advantage plan, there are plans called Hospital Indemnity plans that you can sign up for that will reimburse you for inpatient hospital stays, ambulance service, outpatient surgeries, and other specified benefits.

Answer: Medicare only covers medical devices that are deemed necessary and prescribed by physicians. Smartwatches are considered to be for general health & fitness.

Answer: SilverSneakers and other fitness programs are benefits usually provided with the Medicare Advantage plans. Even though both of you are on Medicare, there is a difference in the plans you enrolled in.

The fitness programs are not included with Medicare Supplement plans or in Original Medicare Part A & B. To receive that benefit, you would need to sign up for a Medicare Advantage plan with the fitness benefit included.

Answer: Yes, if you meet the eligibility criteria. Hospice benefits are covered under Medicare Part A for terminally ill individuals.

Answer: Medicare Part B covers vaccines for the Flu, COVID, Pneumonia, and Hepatitis B. Part B also covers vaccines if you’re exposed to a harmful virus or bacteria by accident, such as a tetanus shot or rabies shot

Part D (prescription drug) plans cover vaccines for RSV, Shingles, Tdap (tetanus, diphtheria, and pertussis/whooping cough), and vaccines that are "reasonable and necessary" to prevent illness and are not covered by Part B. Part D may also cover vaccines required to travel internationally.

Answer: As an insurance broker, I follow specific steps to find the right plan for my clients.

I always enter their medications and dosages into the system, select their preferred pharmacy along with other local pharmacies where medications might be less expensive, and then the system will list plans by lowest drug and premium cost to highest drug and premium cost. I compare costs across many plans and explore available financial assistance programs like Extra Help or manufacturer programs you may qualify for.

If you do not work with a local broker, use Medicare.gov to input your specific medications and dosages to see how costs will vary across plans in your area.

Answer: There will be significant challenges to face because more and more people are signing up for Medicare. That is due to people living longer and rising healthcare costs.

The number of Medicare beneficiaries continues to rise, putting a strain on the program's resources. People living longer means they will need Medicare coverage for a longer period of time. The costs of medical care is increasing nationwide, leading to higher overall Medicare spending.

The combination of these factors poses a significant threat to the financial sustainability of Medicare, potentially requiring future reforms and adjustments to maintain its long-term viability.

Answer: Medicare Part A & B do not cover dental implants, however, some of the Medicare Advantage plans (Part C) that offer dental benefits may cover implants and/or other services.

There may also be some other standalone dental plans that offer coverage for dental implants.

Answer: You can request an adjustment from the Social Security Administration by filing Form SSA-44. This form allows you to demonstrate a life-changing event, such as retirement, that has affected your income and may qualify for a reduction or elimination of the increased premium.

If your income drops significantly, you may qualify for the Medicare Savings program, which can help cover the Part B Premiums.

Answer: Before making any decision, you should review both options. Check the cost of your medications with a standalone Part D plan and the Medicare Advantage plans with drug coverage.

When on Medicare, you have the option to select a Medicare Supplement with a Standalone Part D plan (prescription drug plan) or select a Medicare Advantage plan with prescription drug coverage.

The option you choose will depend on your budget and income. I would never recommend someone have just Medicare A & B with a Standalone Part D plan because then they would be responsible for all of the Part A & B deductibles and copays.

Once you decide which option is best for you based on your budget, you can search for the Standalone Part D or Medicare Advantage plan with drug coverage that is best for you based on your medications.

As a broker, it is my responsibility to help my clients find the perfect fit.

Answer: Most Medicare Advantage plans cover more than just cleanings. This is something that your broker or agent should have gone over with you. Your plan's summary of benefits should also provide more details as to what your plan will and will not cover.

As an insurance broker, I always discuss the benefits of my clients' plans or any plans I recommend. You should be able to call your agent/broker and have them clarify, or you can contact me, and I will be happy to review it with you.

Answer: It's no secret that trying to understand the different parts of Medicare can be overwhelming. Navigating the world of Medicare is challenging. Enrolling can be difficult, but with guidance, it becomes easier. However, enrollment in Medicare A and B is just the first step!!!

You have a choice to make. Which option will best help you cover what Medicare doesn't? That involves choosing between a Medicare Supplement (Medigap) with a stand-alone Prescription Drug Plan or a Medicare Advantage (Part C) plan. There could also be penalties you are not aware of.

I understand the unique concerns you face. It can be tough to find trustworthy information. I am here to provide the clarity and direction you need to move into this next stage of your life with confidence and ease.

I recommend that clients sit down with a professional who knows how to assist them. I don't recommend working with someone over the phone. Find someone local who has good reviews and let them assist you.

Answer: What you paid in all those years covered Medicare Part A premiums. When you retire, Medicare Part A is free if you worked for the last 10 years. Medicare Part B will have a premium that you will pay.

Your costs for specialist visits are likely because of deductibles, coinsurance, copays, or even the fact that you are seeing an out-of-network doctor.

If you are ONLY covered by Medicare Part A and B, Medicare Part B covers doctor's services, but it has a deductible and coinsurance.

If you are covered by Medicare Part A, Part B, and a Medicare Supplement, it will depend on what supplement you are covered by. Plan F has no copays, coinsurance, or deductible. Plan G has a small deductible to meet, then it will cover everything 100% for the rest of the year. Other plans will have deductibles and coinsurance.

If you are covered by Medicare Part A, Part B, and a Medicare Advantage plan, there will be copays that you must pay until you reach the maximum out-of-pocket limit on the plan. Depending on where you live and what plan you are covered by, that maximum out-of-pocket can range anywhere from $2,000 up to $10,000.

There is also the issue that your specialist may not accept Medicare assignment (they agree to bill Medicare directly), so they charge you more (15%) than the Medicare-approved amount, which leads to a balance you have to pay.

Answer: Some HMO plans may allow you to see a specialist out-of-network, but you will have higher out-of-pocket costs. It may all depend on the plans within your area.

I highly recommend sticking with in-network doctors to keep your medical expenses lower. HMO plans typically do not cover any costs for out-of-network doctors. If you wish to see doctors outside the plan's network, a PPO would be the way to go.

Answer: Nutrition counseling would be covered by Medicare Part B under Medical Nutrition Therapy. This is available for any Medicare beneficiary who has been diagnosed with diabetes, kidney disease, or who has had a kidney transplant within the past 3 years.

This service may also include counseling for beneficiaries who have high cholesterol, high blood pressure, or are obese under certain circumstances.

Answer: The most frustrating misconception I have to clear up most of the time is that Medicare Advantage plans are horrible.

They are not horrible, they are just not explained properly by many agents who sell them, which leads to unhappy Medicare beneficiaries.

Medicare Advantage plans are good for people who are lower income and can't afford to pay monthly premiums for Medicare Supplements and Standalone Prescription Drug Plans. If you do not go to the doctor often, your out-of-pocket expenses are less, however, we never know when something will happen or when we will become ill. There are ancillary products available with lower premiums that can help combat the copays for inpatient hospital stays, ambulance service copays, outpatient hospital surgeries, and more.

Medicare Advantage plans are also good for older beneficiaries who have reached the point where they are paying $300 - $400 per month for premiums on a med sup. At that point, the max out-of-pocket on a Medicare Advantage plan is less than the monthly premiums they would be paying for a med sup.

Answer: Yes, losing your employer coverage or any other creditable coverage generates a guaranteed issue period to sign up for a Medicare Supplement (Medigap) plan.

You only have 63 days to enroll after losing your employer coverage. I recommend signing up for the Medigap plan before employer coverage ends, so that you have coverage instead of going without coverage.

Answer: No, mental health services are not fully covered by Original Medicare. There are some mental health services covered, but they may be limited, and there are out-of-pocket costs associated.

Answer: All parts of Medicare have some cost associated, whether it be a premium, deductibles, copays for services, or even a max out-of-pocket.

Premiums are the payments you make for the coverage. Deductibles are the amount you must pay out-of-pocket before your coverage will pay anything. Copays are the amount you pay for specific services after meeting your deductible.

Medicare Part A is free once you retire if you or your spouse worked for the last 40 quarters (10 years) before you signed up, because you paid taxes while working. Medicare Part A:

* Has a deductible for each benefit period (every 60 days) for inpatient hospital stays.

* Has copays for hospital stays longer than 60 days.

* Has daily coinsurance for days 61-90 and 91-150.

Medicare Part B has a premium that comes out of your Social Security check before it is dispersed to you. If you are not receiving Social Security, you must pay the premium for Part B out-of-pocket until you start drawing your Social Security. Medicare Part B:

* Has an annual deductible.

* Does not have copays for most services.

* Has a 20% coinsurance for most services after the deductible is met.

Medicare Supplements (Medigap) provide benefits to help cover out-of-pocket costs like deductibles, coinsurance, & copays. Each Med Sup has a premium, & each one has different benefits. Medigaps:

* Help pay the 20% coinsurance for services covered by Original Medicare Part B (medical insurance).

* Many cover the Medicare Part A (hospital insurance) deductible.

* May cover additional days in the hospital after Medicare benefits are used up.

* Some may cover costs for skilled nursing facilities, hospice care, excess charges from non-participating providers, & foreign travel health care emergencies.

Medicare Advantage usually does not have premiums, but may have a deductible(s), has copays for services, & an annual max out-of-pocket.

Answer: A smaller workforce would mean fewer people paying taxes that fund Medicare. This could cause an increase in the cost of coverage for a growing elderly population.

Answer: Medicare Part B typically covers outpatient physical therapy, occupational therapy, and speech-language pathology when deemed medically necessary by your doctor or therapist.

If you have a Medicare Supplement or a Medicare Advantage plan, you can contact your broker/agent and they can verify your benefits.

Answer: Medicare usually does not cover any health services, supplies, or prescriptions you receive outside the US.

Some Medicare Supplement plans may offer limited foreign travel emergency coverage, typically with a deductible, copay, and lifetime limit.

Medicare Advantage plans are not required to provide coverage for international travel. Some plans may offer benefit coverage for emergency or urgent care while traveling abroad.

Beneficiaries should review their specific plan's terms and conditions before traveling to understand the extent of coverage they may have.

Answer: The main reason is financial pressure. The Inflation Reduction Act (IRA) reduced reimbursement payments to Medicare Advantage plan insurers and capped prescription drug costs.

It is harder for insurers to offer the same benefits and coverage while reimbursements are being cut. Many insurers are reducing the number of plans they offer or pulling out of the market altogether.

Answer: I do not feel it is suspicious, but it is against regulations. Offering such gift cards to entice a beneficiary to enroll is not permitted.

Offering gift cards to beneficiaries for completing health assessments is permitted, but not for enrollment.

Answer: Late enrollment penalties are often overlooked. When working with the right broker/agent, they should educate you on all aspects of Medicare and your options.

Medicare Part B and Part D (prescription drug plans) both have a late enrollment penalty if you go without creditable coverage for a period of time.

Answer: You will have to obtain a valid power of attorney (POA) or a court-appointed guardianship/conservatorship. It should explicitly grant the power to handle healthcare and Medicare-related decisions. If your parent cannot sign a POA, you will have to petition the court for guardianship/conservatorship.

If you decide to petition the court, you will need to gather the necessary documents and information required by the state where you reside. You may need to provide evidence of your parent;s incapacity and why a guardian or conservator is needed. The court will likely conduct a hearing and may appoint an attorney to represent your parent's interests.

Answer: First, I wish every Medicare Beneficiary knew that there are people willing to sit down with them and explain all of their options, go over the plans available in their area, and help them find the right plan to fit their needs.

Working with someone over the phone doesn't always get you the best results. Working with someone who only represents one company doesn't always provide you with the best coverage to fit your needs. Medicare plans available are not a one size fits all, meaning, what may be good for your neighbor, friend, or spouse -- may not be right for you.

Answer: I sit down with each client, even clients who have been on Medicare for a while, and I explain the ins and outs of Medicare Part A & B, Medicare Supplements, Medicare Advantage Plans (Part C), Medicare Prescription Drug Plans (Part D), and other plans they may need to cover what Medicare doesn't cover.

I also do Medicare Seminars from time-to-time with groups of people to explain how Medicare works.

Answer: No, Medicare does not fully cover nursing home care. Medicare Part A may cover a short-term stay in a skilled nursing facility (SNF) after a hospital stay, but it does not cover long-term custodial care.

Alternatives to Medicare for paying for nursing home care include Medicaid, long-term care insurance, and private pay.

Some life insurance policies or even annuity products offer living benefits that are built in to the plan that will help cover SNF expenses.

Answer: If you changed your plan on your own, there should have been a tool on the company's website to verify that your doctors were in their network.

If you worked with an agent or broker, they should have verified that all of your doctors were in the network.

It could be as simple as the doctor falling out of network after you signed up, or the company website showing the doctor in network when the doctor isn't. I have had both of these scenarios happen to a few of my clients

Answer: Medicare Advantage Plans (Part C) can be changed during the Annual Enrollment Period - October 15th to December 7th, or during the Open Enrollment Period - January 1st to March 31st. There are also some Special Election Periods that can be used, such as:

* You change where you live

* You lose your current coverage

* You have a chance to get other coverage

* Your plan changes its contract with Medicare

* Other special situations

Medicare Supplement plans can be changed at any time throughout the year if you qualify medically. Some states even have guaranteed issue periods such as 60 days following your birthday, loss of creditable coverage through employer or another plan, or if the plan exits the market.

Prescription Drug Plans (Part D) can only be changed during the Annual Enrollment Period - October 15th to December 7th, unless there is a Special Election Period that would allow you to change.

Answer: Rely on official resources such as Medicare.gov or HealthCare.gov.

Be wary of unsolicited calls or emails claiming to be from Medicare.

Review plan documents such as the plan's complete Summary of Benefits and Evidence of Coverage (EOC). The EOC is a legally binding document outlining coverage in the plan.

Answer: Working with a local agent/broker gives you a more personalized approach. They provide support for issues you experience, offer face-to-face relationships, and are most likely more knowledgeable about plans in your area.

Answer: Losing your spouse while covered by their employer-sponsored coverage means a couple of different things.

One - if they are still working, you will lose your insurance coverage. Two - if they are retired and you are both covered under an employer-sponsored retirement insurance plan, it will all depend on how the plan is set up.

The way to handle it:

1) If you are eligible for Medicare and your spouse's employer-sponsored coverage ends, you will have a Special Enrollment Period (SEP) to enroll in Medicare Parts A and B. If you were only covered under your spouse's employer plan, you'll need to take action to ensure continuous coverage. That means signing up for Medicare Part A and B as well as electing other coverages for what Medicare Part A and B do not cover such as a Medicare Supplement with a Prescription Drug plan or Medicare Advantage plan.

2) If you already have Medicare A and B, you will have a Special Enrollment Period (SEP) to enroll in a Medicare Supplement with a Prescription Drug Plan or a Medicare Advantage plan with Prescription Drug coverage included.

Answer: Medicare usually does not cover experimental treatments or clinical trials. Medicare will typically only cover the routine costs associated with participating in certain approved clinical trials, including items and services that would normally be covered if not participating in the trial, such as standard medical care and treatment of trial-related side effects.

Answer: Original Medicare with a Part D (Prescription Drug Plan) may be preferable because it offers nationwide access to any Medicare-participating provider, whereas Medicare Advantage plans are typically limited to a specific geographic service area.

Some Medicare Advantage plans may offer state-to-state coverage, while others limit their coverage to a specific defined area.

Answer: Medicare can cover home health services after surgery, but it also depends on the criteria. Medicare Part A covers home health after a hospital stay or surgery. In contrast, Medicare Part B covers services without a hospital stay or surgery as long as it is deemed medically necessary.

Answer: Limited provider network and potentially limited access to care. Depending on the plan you are enrolled in, you could have a Health Maintenance Organization (HMO) network, a Preferred Provider Organization (PPO) network, or a Private Fee-for-Service (PFFS) network.

Answer: The biggest disadvantage is limited provider networks and potential for limited access to care.

Medicare Advantage plans operate in specific networks. Depending on which plan you are enrolled in, you could have one of the following networks:

1) Health Maintenance Organization (HMO)

2) Preferred Provider Organization (PPO)

3) Private Fee-for-Service (PFFS)

Answer: Medicare Part A covers inpatient hospital stays, but not completely covered.

Medicare Part A has a deductible for the first 60 days of your hospital stay. Days 61-90 have a copay per day when you are still in the hospital as a patient. Days 91-150 are your lifetime reserve days, and there is also a copay per day for those if you are still in the hospital during that time.

Medicare Part A also covers up to 100 days of skilled nursing facility care, but only if you first had a qualifying inpatient hospital stay (at least 3 consecutive days).

Answer: The biggest mistakes Medicare beneficiaries make when enrolling are:

1) Misunderstanding how Medicare works

2) Choosing to do it on their own and failing to review all their plan options

3) Enrolling in the wrong plan

4) Failing to enroll on time to avoid penalties

Answer: CHEAPEST IS NOT ALWAYS THE BEST.

Everyone's situation is different, and insurance is not a one-size-fits-all. Each Medicare beneficiary needs to review all of their options to find what will work best for them.

Working with a broker/agent can ensure you get the assistance you need.

Answer: Medicare primarily covers skilled medical care, but not the daily living activities such as bathing, dressing, or using the bathroom, which are usually where help is needed in long-term care settings.

This often leads to financial strain and unexpected expenses when needing long-term care services.

Answer: Usually, it is because of the broader choice of providers and fewer restrictions on where you can receive care.

Medicare doesn't operate on a network like Advantage plans do. Medicare Advantage plans have HMO, PPO, & PFFS networks.

Answer: Sticking with Original Medicare poses a significant financial risk. Without a Medigap plan, you're responsible for the full amount of the Part A deductible and 20% coinsurance for Part B expenses.

Medigap plans typically cover these costs as well as potentially extended hospital stays beyond Medicare's 60-day limit.

Original Medicare has no out-of-pocket maximum, meaning your costs can continue to accumulate over time without a Medigap.

Answer: Lower the prices of drugs for seniors by capping costs, negotiating prices with manufacturers, and implementing rebates for price increases above inflation.

These changes will reduce out-of-pocket costs, potentially increasing access to medications, and even leading to some unforeseen consequences.

Answer: The best answer is to speak with your agent/broker, who can help you. Your agent/broker should create a list of your medications and dosages to research.

If you do not choose to work with an agent or broker, you'll need to compare plans and their formularies, considering premiums, copays, and the network of pharmacies.

1) Create a list of your medications and dosages.

2) Go to www.medicare.gov

3) Scroll down to "Find health & drug plans" and click on "Find Plans Now."

4) Enter your zip code and click "Continue."

5) Select "Medicare drug plan (Part D)" then click "Find Plans."

6) Follow the prompts to select the options that apply to you.

7) Add all your medications to the list, then click "Done Adding Drugs."

8) Select your pharmacy preferences then click "Continue to View Plans."

NOTE: I always recommend searching with Mail Order and 4 local pharmacies selected

to get a better range of options.

9) Now, compare the plans that are available for your area and choose one.

Answer: The short answer is "yes, you can." Medicare Supplements are not like Medicare Advantage Plans. Medicare Supplement policies are underwritten by the insurance company, and each company has different underwriting guidelines.

For a Medicare Supplement plan, after your initial enrollment, you would have to medically qualify to change plans, and by that, I mean that you would have to be healthy enough to make it through underwriting. If you do not medically qualify, some states have guaranteed issue periods called the Birthday Rule, where you can change your Medigap plan within the 60 days following your birthday each year to get lower premiums.

Answer: From the question, I assume you are either referring to a Medicare Advantage plan or a Part D (prescription drug) plan. In that case, yes, these types of plans vary between locations and even insurers.