Don Golding, Medicare Insurance Broker

Answer: Some plans do offer that as an incentive, and, if you are like me, ask yourself why? As an independent agent, I do not offer gift cards or attempt to steer you toward a particular plan. My goal is to be your guide, helping you choose a plan you are most comfortable with.

Answer: Inflationary pressures are real. Healthcare can be a major expense for retired people or anyone with a "fixed income". How you budget and the steps we recommend depend on the type of Medicare plan in which you are enrolled.

With Supplemental plans, the out-of-pocket costs are generally controlled; it is the premiums that continue to rise. Our current recommendation is to budget a 10% to 20% increase in yearly premiums.

With Advantage care plans, the premiums are generally low, but it is the co-pays, co-insurance, and maximum out-of-pocket limits that change annually.

You can shop for a plan that fits your current circumstances, add ancillary plans like Critical Care plans and Hospital Indemnity plans, and always be aware that, as we age, statistically, our healthcare costs do rise.

Answer: All Part D plans, whether a "stand-alone" plan or part of an Advantage Care plan, have a specific list of covered prescription medications. That list is called the plan formulary. The key is to find a plan that covers your prescriptions. As an independent broker, we compare multiple plans to help you find the one that suits your needs.

Answer: Most Advantage plans have local networks. Unless you have a plan that includes a travel benefit, you will be limited to emergency care only if you are out of your service area. Original Medicare, along with a supplemental plan, allows coverage in all 50 states. If you spend significant time in multiple U.S. locations, then you may want to consider Original Medicare and a supplemental plan for your health coverage.

Answer: Once you reach your Part D Maximum Out-of-Pocket in a calendar year, your covered prescriptions will be a zero-dollar cost-share. The 2026 Maximum Out-of-Pocket is $2100. Your actual out-of-pocket may be less, depending on your plan and any assistance you may be receiving.

Answer: In general, PPOs allow you to self-refer to a specialist without a referral from a primary care physician. PPOs usually allow you to receive services outside the network, typically at a much higher cost-sharing. The trade-off, in most cases, for this flexibility is reduced benefits, higher copays and cost-sharing, and a higher maximum out-of-pocket limit than with an HMO. Plans vary widely across the country; neither HMO nor PPO is the "right" answer for everyone. It depends on YOUR needs. Contact an Independent Medicare Broker to discuss your unique situation.

Answer: In most cases, we recommend additional coverage to offset out-of-pocket cost sharing and other non-covered expenses. Critical Illness plans, Cancer plans, Hospital indemnity plans, and Short Term Home Health plans are excellent ways to protect yourself from unexpected expenses.

Answer: When it comes to Medicare choices, most regrets come from a lack of knowledge or understanding of how a plan works. Whether it's an Advantage Care plan with a network of doctors or a Supplemental plan with ever-higher premiums, knowing how it works and what ot expect is key to high satisfaction. Neither Original Medicare (with a Supplemental plan) nor an Advantage Care plans are perfect. Both have upside AND downsides. The critical factors are understanding how the plan works and choosing one that fits your individual needs.

Answer: Generally, Medicare Advantage does not offer "extra" coverage for breast cancer services. All Advantage plans will cover "medically necessary" treatments. A great way to have extra coverage is through an Indemnity Plan, such as a Cancer plan or Critical Illness plan. These plans are relativly inexpensive and the benefits can be paid directly to the benificiary.

Answer: Ask the agent for his state license number. Then check your state's Department of Insurance website to see if the agent is local or out of state. Most states also post any complaints or grievances. Additionally, ask the agent how long they have been working in the Medicare space and how many companies they represent. A final consideration might be verifying if the agent represents both Advantage care plans and Supplemental plans, allowing you a full spectrum of coverage options.

Answer: Like many things in life, there are advantages and disadvantages to the choices we make. In the case of Medicare PPOs v. Medicare HMOs, it depends on what is important to you. Generally speaking, PPOs allow you to self-refer to a specialist without the need to get a referral from your Primary Care Physician. You can also go outside your network and still receive covered care, although, in general, at a much higher cost share. PPOs usually have higher copays, coinsurances, and higher maximum out-of-pocket limits. It is best to consult an independent broker to compare all of your options and find a plan that fits your individual needs.

Answer: Plan N covers an MRI; however, there may be a copay involved. Additionally, if the facility does not accept Medicare Assignment, you may be responsible for excess charges.

Answer: Yes, all Advantage Care and Prescription Drug plans send out an Annual Notice of Change, usually around the first week of October. It is important to review the changes for the upcoming year. If you have questions or concerns, I recommend you contact a local broker to help you compare your options.

Answer: Yes, you should automatically be enrolled in Medicare, Parts A and B. You should receive your Medicare (red, white, and blue) care approximately 3 months before your birth month. If you were born on the 1st day of the month, everything starts one month sooner. Once you receive your card you will be able to shop for the coverge that fits your needs.

Answer: My experience with Medicare tells me that it will be a few years before mainstream wearables are accepted and covered by Medicare. In general, I have found Medicare to take a slow, cautious approach to new technologies of all kinds. A good example is the adoption of continuous glucose monitors. It took several years for Medicare to cover these devices, but now they are widely used and covered in most Medicare plans.

Answer: The short answer is: it's not! Medicare, like most things, is not a "one size fits all" proposition. Each type of plan has its own unique set of pros and cons. A good independent broker will help you discover the type of plan that is most appropriate for you!

Answer: The Maximum Out-of-Pocket is a very important consideration in any Advantage care plan. As the name implies, it limits the amount you spend, on an annual basis, for your health care. All covered charges add up toward your MOOP. Prescriptions and non-covered charges do not count. In general, a lower MOOP is desirable in any plan.

Answer: There are several ways you can find doctors in your network. Most plans offer an online portal for services like doctor networks. You can contact customer service by calling the number on the back of your plan's ID card. If you worked with an independent broker, like me, we can always help as well!

Answer: It's hard to predict the future! Twenty-five years ago, we were using dial-up modems, and "AI" was something out of science fiction. I believe we will see a gradual shift toward AI use for routine approval and then more complex cases as the models improve. I do not think there will be a time when AI will be the sole decision maker. I believe there will always be a human in the loop.

Answer: In the Medicare space, HMOs have advantages and disadvantages. HMOs require you to stay in network to receive any benefit, usually require a referral from your PCP to see a specialist, and may have prior authorization requirements. However, HMOs often offer the richest benefits, lowest copays, and maximum out-of-pocket protection. Generally, they also provide desired ancillary benefits, such as dental, vision, hearing, and over-the-counter medications, among others. As with all Medicare plans, it is vital to know the benfits and understand how the plan works. Everyone is different; one type of plan does not work for all. Find an agent who represents a broad variety of plans to help you find the plan to fit your needs.

Answer: There are several reasons a beneficiary might elect to enroll in a PPO. Most PPOs allow you to see a specialist without a referral and have the choice to see an out-of-network provider, should you choose to. With that flexibility comes increased costs, both in-network and out-of-network. Like most things in life, "one-size" does NOT fit everyone; it's the same with healthcare. This is why we highly recommend having a one-on-one appointment with an agent who represents most plans in your area, to find a plan that "fits" you.

Answer: Advantage plans can be a cost-effective alternative to regular Medicare. They are private insurance companies with a Medicare contract to cover your health. Many have additional, ancillary benefits not offered in original Medicare. No plan is perfect, whether original Medicare, Medicare plus a supplemental plan (with a stand-alone drug plan), or an Advantage Care plan. All the options have benefits and drawbacks. Over 34 million beneficiaries are currently enrolled in Advantage plans. As always, I recommend a thorough review of your individual needs to find a plan that fits your unique circumstances.

Answer: No, neither Advantage nor Original Medicare (with a supplemental plan and prescription plan) is the correct fit for everyone. Both types of coverage have their advantages and their downsides. Medicare Advantage plans are gaining popularity due to their low or no monthly premiums and the rich benefits. Each person has their unique situation. Consult with an independent broker to determine the type of plan that best suits your needs.

Answer: I do not recommend Medicare ONLY (A & B) as a solution. The roughly 20% coinsurance and the fact that there is no Part D coverage in original Medicare makes it unsuitable for most beneficiaries.

A better question might be, "Is Original Medicare, plus a Part D plan, and a Supplemental (Medigap) plan, or an Advantage plan better?" - The answer to that question depends on you. One option is not "better" than the other; there are many factors involved. I recommend you discuss all your options with a licensed agent who represents both Supplemental and Advantage plans, and represents multiple carriers. One solution is not right for everyone.

Answer: Supplemental (Medigap) plans do not have open enrollment periods, so it is possible to change plans anytime; however, if you are outside a guaranteed issue period, you may have to go through medical underwriting. The results of the underwriting could be higher rates or denial. The underwriting process will vary by state, carrier, and plan. It is recommended that you discuss your specific needs with a licensed, independent agent before making any changes.

Answer: I would be skeptical of any agent who "pushes" clients into either category - Advantage or Supplemental plans. One type does not fit all health and financial situations. By conducting a thorough needs analysis, an agent can determine the type of plan to recommend to a client. The client should always have the final say and should never feel pressured into a decision.

Answer: For many people, Medicare and associated Medigap or Advantage plans can have significant savings for your parents, whether or not they have retired. I would enlist the assistance of an independent broker, representing a variety of options, to help explain how Medicare and the various plans work. The discussions can take place in-home, at an office, via Zoom, or by phone. Having a local expert on board to compare and contrast opinions will help your parents feel at ease when making Medicare decisions.

Answer: The type of coverage, Supplemental (Medigap) vs. Advantage, costs, and your value system are very personal decisions. Everyone's circumstances are different. If the cost of your Medigap plan is becoming a burden or it no longer fits your lifestyle, I recommend a review with a local, licensed broker in your area. If appropriate, you can switch to an Advantage Care plan during the next annual enrollment period.

Answer: Hospitals negotiate with insurance companies and plans for payments. Depending on the plan's payment structure, a hospital (or any care provider) makes a business decision to accept the plan(s). Hospitals generally sign multi-year agreements with the insurance carriers.

Answer: There's no one question. Everyone's situation is unique. A better approach to your situation is to understand how your plan works for you. What are the premiums? Copays and coinsurance? Is there a deductible? Are my medications covered? What's NOT covered? I recommend a comprehensive analysis of current circumstances and future needs. I would suggest this be done with an independent broker to maximize your choices.

Answer: To minimize IRMAA (Income-Related Monthly Adjustment Amount) surcharges on your Medicare Part B and Part D premiums when income changes, focus on strategies to reduce your Modified Adjusted Gross Income during years of high income. This includes making tax-deductible contributions to retirement accounts, donating appreciated assets to charity, and potentially delaying or timing Roth conversions to avoid unexpected income spikes.

Answer: Premiums are payments for a policy; they do not count towards a deductible or a maximum out-of-pocket expense. Most people will pay the Medicare Part B premium. There may be additional premiums based on the type of additional policies a beneficiary has enrolled in.

Deductibles are the money you pay before a plan pays for services. Generally, these payments count towards your maximum out-of-pocket.

Copays (and co-insurances) are the costs of your services and count toward your maximum out-of-pocket.

You can find specific amounts in your plan's summary of benefits document.

Answer: Broadly speaking, Part A covers Hospitalization, skilled nursing confinement, and Hospice. There is a Part A deductible, and copays may apply as well. Part B also has a deductible and covers roughly 80% of covered expenses. Additionally, there are no maximum out-of-pocket limits. Neither Part A nor Part B covers prescription drugs - Part D.

I recommend looking at either a Supplemental (Medigap) Plan with a separate Part D prescription plan or an Advantage Care plan with drug coverage built in to cover the "gaps" in original Medicare.

Answer: Local agents, especially independent brokers, have in-depth knowledge of plans and networks in your area. Additionally, face-to-face communication is the most complete form of communication. This combination of "presence" and local knowledge helps beneficiaries find a plan suited to their specific needs.