Diane Poythress, Medicare Insurance Agent

Answer: A Medicare Special Needs Plan (SNP) is a specialized type of Medicare Advantage plan (Part C) that limits enrollment to individuals with specific diseases, or who are dually eligible for Medicare and Medicaid. These plans tailor their benefits, provider networks, and drug formularies to best meet the unique needs of their members.

Three Primary Types of SNPs:

Dual Eligible Special Needs Plans (D-SNP): For individuals who qualify for both Medicare and Medicaid.

Chronic Condition Special Needs Plans (C-SNP): For individuals with specific, severe, or disabling chronic conditions (e.g., dementia, diabetes, end-stage renal disease).

Institutional Special Needs Plans (I-SNP): For individuals who live in a nursing home or require nursing care at home for 90 days or longer

Answer: There is no easy way to answer this question.

Why are you choosing to go with Medicare Advantage over original Medicare? If you need to go to a center of excellence, i.e., Mayo Clinic, then a Medicare supplement is your only option. If you travel and need to see doctors outside your network, either Original Medicare or a PPO will work for you.

Both original Medicare and the Medicare Advantage PPO plan allow you to see doctors out of “next work”. The PPO includes additional benefits of the Advantage plans, such as dental and vision. Many Medicare Advantage PPO plans have low or no monthly premiums. With the PPO plan, you typically may have higher copays and a higher max out-of-pocket when you choose to go out of network.

With Original Medicare, you can choose any doctor who accepts Medicare. However, you have copays and deductibles with Original Medicare. Now, most people choose a Medicare supplement to cover the copays and deductibles that original Medicare does not cover. They also need to enroll in Part D for prescriptions. Original Medicare also doesn’t cover dental or vision. If you need dental and vision, you will need to enroll in a plan.

Unless you have planned for retirement and set aside:

• Part B monthly premium 2026 $202

• Medicare supplement monthly premium average cost Plan G $160 + first $283 of Medicare costs

• Medicare supplement monthly premium average cost Plan N $130 first $283 of Medicare costs and $20-50 copays for doctor and emergency room visits.

• Prescription plan monthly premium estimate $0-$50 + cost of prescriptions

I guide my clients with probing questions and walk through the numbers to determine whether it is more advantageous for them to choose a Medicare Advantage PPO plan or to remain with Original Medicare and add a supplement, Part D, and vision and dental coverage.

Biltmore Health Insurance

Diane Poythress

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Answer: First question. How did you enroll in a plan that you did not qualify for? Yes, you will have a SEP to enroll into a MAPD plan.

Answer: Typically, to continue seeing your doctor after you are on Medicare, it depends on the plan you choose. If the plan you choose is an HMO and your doctor is in the network of the Plan(HMO), then yes, you can see your doctor.

There are Medicare Advantage plans called PPO, which allow you to see a doctor outside of the plan network. If you see a doctor outside of the plan network, then you may have higher copays and higher deductibles.

There are Medicare supplement plans. You can see any Doctor and use any hospital across the United States that accepts Medicare.

The doctors choose what plans they will accept. So if you are considering choosing a Medicare Advantage plan, you should ask your doctors what plans they accept. Now, with that being said, doctors can choose year to year whether or not to take a plan. As well as during the year, a doctor can move to a different office and leave the network. You can do your best to confirm your doctor is in network; however, things can change.

Answer: Yes, when you turn 65, your Medicare enrollment will be automatic because you are receiving Social Security retirement benefits, and you don't need to complete a new application. You will receive a welcome package with your Medicare card and information about your benefits in the mail approximately three months before your 65th birthday

When you turn 65, your entitlement to Medicare will change from being based on disability to being based on age, but the benefits and coverage remain the same.

Look over your Medicare options. You will then have the opportunity to make important decisions about your coverage, such as adding drug coverage, even though you've already qualified for Medicare based on your age.

Decide if you want to stay on original Medicare, or enroll in a Medicare Advantage Plan (Part C) or add a Medigap plan and a Part D prescription drug plan. If you have any questions please do not hesitate to reach out for further clarification and assistance with enrollment.

Answer: I take the time to understand your individual healthcare needs and preferences, offering tailored recommendations.

Working with a Medicare agent can be beneficial for several reasons, primarily because I offer expertise, personalized guidance, and can help you navigate the complexities of Medicare. Agents can save you time, potentially money, and reduce the stress of choosing and enrolling in a plan. I can also provide ongoing support and help you understand your coverage throughout your retirement.

Answer: Long-term Care

One hidden Medicare expense that many people overlook is the cost of long-term care, particularly custodial care in a nursing home. While Medicare Part A does cover some skilled nursing facility care after a qualifying hospital stay, it doesn't cover the long-term custodial care many seniors eventually need. This type of care, which includes assistance with daily tasks like bathing, dressing, and eating, can be very expensive, easily reaching $5,000 to $10,000 per month depending on location.

Answer: Yes, it's highly likely that Medicare Advantage (MA) plans will offer more digital health tools like apps by 2030, building upon existing trends and advancements.

Some digital health tools already being integrated into Medicare Advantage plans include digital therapeutics, personalized care plans, telehealth, remote monitoring devices, and member portals/apps. This trend is expected to make healthcare more accessible for seniors.

Answer: Whether Original Medicare or Medicare Advantage is "better" depends on your lifestyle, individual needs, and preferences. Original Medicare offers freedom to choose any doctor or hospital that accepts Medicare, while Medicare Advantage plans often have lower premiums and may include extra benefits like vision, dental, and hearing coverage. However, Medicare Advantage plans typically have provider networks and may require referrals, potentially limiting choices.

There is no right or wrong; it's about your needs and lifestyle.

Suppose you have set aside funds for a monthly premium. If you value freedom of choice and don't mind potentially higher costs, Original Medicare might be a good fit, especially if you enroll in a Medigap plan.

If you prefer lower premiums, extra benefits, and are comfortable with a network and potential referrals, Medicare Advantage could be a better option.

Answer: While Medicare Supplement (Medigap) plans offer standardized benefits, the monthly premiums can vary significantly between insurance companies. This means that even if you have the same plan letter, you could be paying a different amount than someone with the identical coverage from a different insurer. To potentially save money on your Medicare Supplement, consider these options:

1. Shop around and compare premiums

2. Consider switching plans or companies

3. Explore High-Deductible options (Plans F and G)

Answer: Medicare deductibles are not fixed and can increase each year.

The Centers for Medicare & Medicaid Services (CMS) determines the deductible amounts for Parts A and B.

If you have a Medicare Advantage plan (Part C) or Medicare Part D plan (prescription drug coverage), your deductible and other costs can also change each year, as they are set by the private insurance companies offering those plans.

Answer: I can! I am a licensed professional who can guide you through plan options, enrollment, and answer any questions you may have about coverage. When I meet with someone to discuss Medicare, I do my best to explain the "maze and alphabet soup" of Medicare. It is important to get your questions answered before you select a supplement or an advantage plan.

Answer: Medicare generally covers cataract surgery, but seniors can still face out-of-pocket costs. While Medicare Part B covers 80% of the approved costs for the surgery, pre-surgery exam, and post-surgery care after the deductible is met, the remaining 20% and any costs for advanced lens implants or elective procedures are the responsibility of the patient.

Answer: IRMAA, or the Income-Related Monthly Adjustment Amount, can increase your Medicare Part B and Part D premiums if your income is above certain limits. The Social Security Administration (SSA) determines if you owe an IRMAA based on your Modified Adjusted Gross Income (MAGI) from two years prior. For 2025, this means your 2023 tax return is used. If your income triggers an IRMAA, the SSA will send you a notice detailing the surcharge.

Answer: Medicare does not generally cover the costs of assisted living. While Medicare provides coverage for some skilled nursing care in certain situations and some Medicare Advantage plans may offer limited assistance with non-medical services, it primarily focuses on acute medical care, not long-term custodial care.

Medicare primarily focuses on acute medical care and rehabilitation, while assisted living facilities mainly provide custodial care, which includes help with daily living activities, medication management, and supervision. This is why you need to have a plan in place for yourself in case you need assistance.

Answer: You are likely enrolled in different types of Medicare plans, which offer varying benefits. While Original Medicare (Parts A & B) doesn't include SilverSneakers, many Medicare Advantage (Part C) and some Medicare Supplement (Medigap) plans do. Your friend's plan likely includes SilverSneakers as an added benefit, while your plan might not.

Answer: Yes, it allows members to purchase eligible health and wellness products using a prepaid card. These cards are typically loaded with a set allowance, either monthly or quarterly, and can be used at participating retailers like CVS, Walgreens, Walmart, and others, or through mail order or online platforms.

Answer: If you are on a tight budget, comparing Medigap Plan K and Plan G involves weighing lower premiums against potential higher out-of-pocket costs.

Answer: Medicare generally does not cover experimental treatments or the costs of clinical trials, but it may cover the "routine costs" of qualifying clinical trials. Routine costs are those that would normally be covered by Medicare if the patient were not participating in the trial, such as standard medical care and treatment of trial-related side effects.

Answer: Technology will play a significant role in shaping the future of Medicare, impacting how beneficiaries access care, how providers deliver services, and how the program itself is administered. Telehealth, AI, and digital health technologies are expected to become increasingly integrated into Medicare, offering potential benefits like improved access, enhanced efficiency, and better health outcomes.

Answer: Generally, Medicare does not cover medical care outside the United States. There are very limited exceptions, such as if you are in a US territory or if you are traveling through Canada and need to be hospitalized.

Some Medigap plans may offer limited coverage for emergency care while traveling outside the US, typically with a lifetime limit and requiring you to pay a portion of the costs.

It's crucial to purchase comprehensive travel health insurance before your trip to cover potential medical expenses, emergency transportation, and other related costs.

Answer: I find fulfillment in knowing I helped someone find a plan that saves them money or better suits their health needs.