Fred Manas, Medicare Insurance Agent

Answer: Assisting people navigate the myriad of questions and concerns regarding medicare, supplements and advantage plans.

Answer: I provide comparisions evidencing the multiple options/products for the medicare plan(s) you are considering.

Answer: Original Medicare, generally does not cover routine dental care, such as:

dental exams,

cleanings,

fillings,

dentures,

and extractions.

However, there are limited exceptions where Medicare may cover dental services.

e.g.

1.) dental care necessary for a medical condition, such as before or after surgery

2.) dental care provided as part of inpatient hospital care and/or

3.) dental care related to an emergency situation

NOTE: Medicare Advantage (MA) plans, which are private health insurance plans, often include dental services that traditional Medicare does not. Individuals should do a side-by-side comparison of separate dental insurance policies to supplement their Medicare coverage in order to obtain comprehensive dental care.

Answer: The Medicare Prescription Payment Plan MPPP) is a payment option in the prescription drug law that works with your current drug coverage to help you manage your out-of-pocket costs for drugs covered by your plan by spreading them across the calendar year (January–December). Anyone with a Medicare drug plan or Medicare health plan with drug coverage (like a Medicare Advantage Plan with drug coverage) can use this payment option. All plans offer this payment option, and participation is voluntary.

If you select this payment option, each month you’ll continue to pay your plan premium (if you have one), and you’ll get a bill from your health or drug plan to pay for your prescription drugs (instead of paying the pharmacy). There’s no cost to participate in the Medicare Prescription Payment Plan.

Answer: Regular Medicare offers more freedom and flexibility in choosing providers and is generally considered more comprehensive, but can be more expensive.

Medicare Advantage plans can be more affordable and offer extra benefits, but may have restrictions on provider choice and require prior authorization.

Answer: No, mental health services like therapy are not fully covered under Original Medicare, but a substantial portion is covered, according to Medicare (.gov). Original Medicare, which includes Part A (Hospital Insurance) and Part B (Medical Insurance), offers coverage for both inpatient and outpatient mental health services, but there are limitations and out-of-pocket costs involved

Answer: While Medicare generally doesn't allow retroactive enrollment for missed deadlines, a medical emergency could potentially lead to a Special Enrollment Period (SEP). This would allow you to enroll without a late penalty and potentially receive coverage backdated up to six months, but no earlier than your initial eligibility date

Answer: If you're finding Original Medicare bills are overwhelming, a Medicare Advantage plan might be worth considering.

Original Medicare offers flexibility in choosing providers, BUT it lacks an out-of-pocket maximum which could lead to potentially higher costs for those with significant health needs.

Medicare Advantage (MA) plans often have lower premiums and include a limit on out-of-pocket (OOP) spending, thereby offering some financial protection. However, these plans typically have provider network restrictions and may require prior authorization for certain services, which might not be ideal if you need to see a specific doctor or travel frequently.

Answer: If a wearable device is prescribed by a physician and deemed medically necessary (this is key) for a specific condition (like atrial fibrillation), it might be covered under Medicare's Part B if the device is considered a diagnostic device or part of a broader diagnostic service.

Answer: Yes, you can use your Health Savings Account (HSA) to pay for Medicare premiums, including Part B, Part D, and Medicare Advantage premiums.

Once you turn 65 and enroll in Medicare, you can continue to withdraw funds from your HSA tax-free for qualified medical expenses, including Medicare premiums and out-of-pocket costs. Specifically, you can remain HSA eligible after 65 as long as you are employed, enrolled in an HSA-eligible high-deductible health plan (HDHP), and not enrolled in Medicare or other non-HDHP insurance.

You cannot use it to pay for Medicare supplement policies (like Medigap).

Answer: You qualify for a Special Enrollment Period if you've had certain life events:

losing health coverage,

moving,

getting married,

having a baby,

adopting a child,

if your household income is below a certain amount.

Answer: Medicare Part B covers many preventive screenings and tests at no cost.

Many other screenings are covered with no copay or deductible.

Medicare also covers the Annual Wellness Visit (AWV).

However, you may need to pay a share of the cost for some screenings or diagnostic tests, and for any follow-up care needed as a result of a screening.

Answer: Like a good financial plan, insurance takes into account your goals and current financial situation and should evolve as your life changes. In addition to income replacement, life insurance, in particular, can help diversify your portfolio, protect late-in-life risks and even has the potential to provide tax benefits.

Answer: Medicare provides multiple choices from which to choose. The selection process is tailored to the clients needs and wants. Medicare also allows, through certain rules and time periods, for a subscriber to switch from one program to another.

Answer: The prescription drug plans allow for completion amongst the carriers. You can load your runs on medicare.gov and select Search PDP's.

You will be presented with all the options available in your area. Compare three insurers side by side to see who they are similar and how they are different. Select the plan that fits your budget.

Answer: To get straightforward answers from Medicare, try initiating your own call to 1-800-MEDICARE or using the secure online portal on Medicare.gov. You can also explore the online resources and consider contacting a SHIP (State Health Insurance Assistance Program) counselor for personalized guidance.

Elaboration:

Initiate Your Own Call:

Instead of waiting for calls, call Medicare directly at 1-800-MEDICARE.

Secure Online Portal:

Explore the secure online portal on Medicare.gov for information and to manage your account.

Online Resources:

Review Medicare.gov for answers to common questions, including how to enroll, understand coverage, and handle appeals.

SHIP Counseling:

Consider contacting your local SHIP counselor for personalized assistance, as they can provide unbiased information and guidance.

Report Unwanted Calls:

If you are receiving unsolicited calls claiming to be from Medicare, report them to the Federal Communications Commission (FCC) or the Federal Trade Commission (FTC).

Answer: Medicare generally covers the cost of cataract surgery, including the insertion of a standard intraocular lens (IOL), but not advanced or premium lenses that offer more specific vision correction. The "standard" lens covers the basic needs of focusing light on the retina. If a patient desires a lens with features like reduced need for glasses, additional cost is usually the patient's responsibility.

Answer: Medicare coverage gaps refer to the out-of-pocket expenses the subscriber might face beyond what Original Medicare (Part A and B) covers, including deductibles, coinsurance, and copayments. These gaps also encompass areas like prescription drugs, routine vision, dental, and hearing care, as well as some long-term care needs.

Answer: in 2023 U.S. health care spending reached $4.9 trillion or $14,570 per person accounting for 17.6 % of US GDP.

Answer: In summary, the tier your medication is placed on in your Part D plan significantly impacts your out-of-pocket costs. Lower tiers generally mean lower copays, while higher tiers can lead to higher costs.

Answer: The best time to start looking at Medicare options is during the Initial Enrollment Period and the Annual Open Enrollment Period.

The Initial Enrollment Period (IEP) occurs when you are first eligible for Medicare, typically around age 65, and lasts for seven months.

The Annual Open Enrollment Period (AEP) runs from October 15 to December 7 each year, allowing you to switch plans for the following year.

Answer: Summary:

Medicare Advantage plans may offer dental coverage, but coverage varies by plan.

Dental services included in these plans can range from basic cleanings to more extensive procedures.

It’s important to review each plan’s specific dental benefits and any associated costs carefully.

Understanding Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is an alternative way to receiving Original Medicare (Part A and Part B) benefits.

These plans are offered by private insurance companies approved by Medicare and provide all the same coverage of Original Medicare, and often additional benefits like prescription drug coverage, dental, vision, and hearing services.

Medicare Advantage plans may be an attractive option for individuals looking for additional healthcare coverage and often come with different plan types, network restrictions, and cost structures to suit your individual needs.

Answer: Yes, you can enroll in Medicare even if you haven't paid into Social Security due to working overseas. However, you may have to pay a premium for Part A (hospital insurance) and must enroll in Part B (medical insurance). You can enroll in Medicare during a special enrollment period when you return to the United States as a permanent resident.

Here's a more detailed explanation:

Premium-free Part A:

If you haven't worked enough quarters (40 quarters) to qualify for premium-free Part A, you'll need to pay a premium to enroll in Part A.

Part B:

If you are a U.S. citizen or permanent resident who has been living in the U.S. for at least 5 years, you can enroll in Part B.

Special Enrollment Period:

When you return to the U.S. as a permanent resident, you will have a special enrollment period to enroll in Part A and Part B without late enrollment penalties.

Enrollment outside the U.S.:

If you are a U.S. citizen living abroad and don't qualify for Social Security benefits, you cannot enroll in Medicare until you return to the U.S.

Enrollment at the U.S. Embassy or Consulate:

If you are living abroad and wish to enroll in Medicare, you can do so by contacting the U.S. Embassy or Consulate in your country.

Answer: While receiving care through the Indian Health Service (IHS) at no cost, you are not automatically required to have Medicare. However, if you are 65 or older, or have a disability that qualifies you for Medicare, you can still enroll in Medicare and it can work alongside IHS to provide comprehensive coverage.

Answer: No, not all types of blood tests are fully covered by Medicare. Medicare covers blood tests that are deemed medically necessary for diagnosis or treatment of a health condition, but routine screenings or tests done during annual physicals may not be fully covered.

Answer: Yes, Medicare Part B typically covers nutrition counseling for individuals with high cholesterol, but only when it's provided as part of a Medical Nutrition Therapy (MNT) program. To qualify, a doctor must refer you for MNT services, and the nutrition professional must meet Medicare's requirements.

Answer: Medicare Advantage star ratings provide a general indicator of a plan's quality and can influence the level of care you can expect. A higher star rating (5-star being the highest) generally suggests a better overall experience and higher quality of care, while a lower rating may indicate areas where the plan needs improvement.

Answer: Medicare generally does not cover the following six items:

1. Long-term care: This includes custodial care, such as assistance with bathing, dressing, and eating.

2. Dental care: Routine dental checkups, cleanings, fillings, and dentures.

3. Vision care: Eye exams, eyeglasses, and contact lenses.

4. Hearing aids: Hearing exams and the cost of hearing aids.

5. Prescription drugs: Most prescription medications are not covered by Medicare.

6. Cosmetic surgery: Elective cosmetic procedures, such as facelifts and tummy tucks.

Answer: While it's frustrating to be denied a Medigap plan due to health history, it's legal for insurance companies to use medical underwriting to assess risk. This means they can decline coverage or impose restrictions based on your health, especially outside of the guaranteed issue period or other specific situations.

However, you do have rights during your open enrollment period and under specific guaranteed issue rights.

Here's a more detailed explanation:

Medical Underwriting:

Medigap insurers use medical underwriting to assess risk. This involves reviewing your medical history to determine the likelihood of future claims and potential costs.

Guaranteed Issue Rights:

During your Medigap open enrollment period (six months after enrolling in Medicare Part B), you have guaranteed issue rights, meaning you cannot be denied coverage based on health. You also have guaranteed issue rights in other specific situations, such as if you lose coverage from a previous health plan and enroll in Medicare within 63 days.

Denial and Pre-existing Conditions:

Outside of guaranteed issue periods, Medigap insurers can deny coverage or impose restrictions (like waiting periods) for pre-existing conditions.

State Variations:

Some states offer more extensive guaranteed issue protections than federal law, according to United American Insurance Company.

Appealing a Denial:

If you're denied coverage, you may have the right to appeal the decision. You can gather information from your provider, explain your situation, and potentially provide additional medical records according to The National Council on Aging.

In summary: While it's understandable to feel frustrated about a denial, it's important to understand that Medigap insurers can deny coverage based on health history, particularly outside of guaranteed issue periods. However, you have rights during open enrollment and under other specific situations, and you may also have the right to appeal a denial.

Answer: Medicare can work with both Veterans Affairs (VA) benefits and employer-sponsored health plans, but the order in which they pay for medical care can vary.

Generally, if a veteran is eligible for VA benefits, they can choose whether to use those benefits or Medicare, but they generally can't use both for the same service.

Employer-sponsored plans may also be considered primary or secondary depending on factors like the size of the company and the specific coverage offered.

Answer: Following up after discussing Medicare with your parents helps ensure they understand their options, feel supported, and make informed decisions about their healthcare coverage. It also allows you to address any questions or concerns that may arise after the initial discussion and to identify and help address potential gaps in coverage.

Answer: Yes, Medicare Part B will cover acupuncture for chronic low back pain, but with some limitations. Medicare coverage specifically applies when the pain has been ongoing for 12 weeks or longer, and it's not linked to an obvious cause like infection, inflammation, or cancer.

More Details:

Coverage:

Medicare Part B will cover up to 12 acupuncture sessions within a 90-day period.

Additional Sessions:

If the initial 12 sessions show improvement, Medicare may cover an additional 8 sessions.

Annual Limit:

The total number of covered sessions is capped at 20 in a 12-month period.

Provider Requirements:

The acupuncture services must be provided by a qualified healthcare provider, often a licensed physician or other advanced practice provider, who meets specific Medicare requirements.

Cost-Sharing:

After you've met your Part B deductible, you'll pay 20% of the Medicare-approved amount for each covered session.

Answer: Yes, it's possible that your Medicare Advantage PPO plan requires referrals for specialist visits, including dermatologists, even if it's a PPO. While PPO plans generally don't require referrals, some Medicare Advantage PPOs may have specific rules or restrictions.

Here's a more detailed explanation:

General PPO Rule:

PPOs typically don't require referrals from a primary care physician (PCP) to see specialists.

Medicare Advantage PPO Variations:

Medicare Advantage PPO plans can vary in their rules and restrictions, including referral requirements.

Plan Specifics:

It's crucial to review your specific Medicare Advantage PPO plan's details to understand its referral requirements.

Checking Your Plan's Documentation:

Look for information about referrals in your plan's Member Handbook, Evidence of Coverage, or Summary of Benefits. You can also contact the plan's customer service for clarification.

In-Network Restrictions:

Even if your PPO plan doesn't require referrals, you may still need to see specialists who are within the plan's network to avoid higher out-of-pocket costs.

Potential for Missed Coverage:

If you see a dermatologist without a referral, your plan might not cover the visit, even if you're in-network.

Answer: Yes.

Medicare plans and requirements can differ significantly by state, especially when it comes to Medicare Advantage and Medigap (Medicare Supplement) plans.

While Original Medicare (Part A and B) generally offers the same coverage and costs nationwide, private plans like Medicare Advantage and Medigap can have variations in availability, benefits, costs, and even enrollment opportunities.

Answer: Please note:

Critical insurance is not designed to replace your Medicare coverage, rather provide extra cash when you may need it most.

It can, however, be a very important part of your overall financial plan!

Answer: If you're struggling to afford your Medicare premiums, you can explore several options for financial assistance.

State and federal programs, like Medicare Savings Programs and Medicaid, can help cover premiums and other medical costs.

Also, you can consider programs like Extra Help, which provides financial assistance with Medicare Part D prescription drug costs.

Answer: Yes.

You can be denied for a Medicare Supplement (Medigap) plan, particularly if you apply outside of your initial enrollment period or a guaranteed issue period.

Insurers can deny coverage or impose waiting periods for pre-existing conditions outside of these periods.

Answer: The Medicare Advantage 5-Star Special Enrollment Period (SEP) is a unique opportunity to switch to a 5-star-rated plan during a specific time frame.

It is different from both the Annual Enrollment Period (AEP) and the Open Enrollment Period (OEP) in terms of eligibility and timing.

Answer: No, Medicare Supplement plans are not the same as "Medicare Secondary Insurance", although they are related. Medicare Supplement plans, also known as Medigap, are extra insurance purchased to cover gaps in Original Medicare.

"Medicare Secondary Insurance" refers to a situation where Medicare is the second insurance payer after another primary insurance. While a Medigap plan can function as secondary insurance to Original Medicare, it's not the only type of secondary insurance that can exist.

Answer: No, Medicare will not drop you due to your health status.

Medicare is a federal health insurance program, and it does not have the ability to deny or drop coverage based on your medical condition.

However, Medicare Advantage plans (Part C) can be dropped, but not for health reasons.

Answer: Yes, Medicare Part D plans can deny coverage for brand-name drugs even if a generic equivalent isn't available.

However, they are required to cover prescription drugs in certain protected classes, and there are exceptions and appeals processes.

Plans may have rules about what drugs are covered and how they are covered in different categories, often favoring generics.

Answer: Many Medicare Part B preventive screenings are free. This includes screenings for conditions like cancer, heart disease, and sexually transmitted infections, as well as vaccinations and the Annual Wellness Visit. You won't have to pay a deductible or coinsurance for these services.

Here's a more detailed breakdown:

Cancer Screenings:

Medicare covers a wide range of cancer screenings, including breast cancer (mammograms), cervical cancer (Pap tests), colon cancer (colonoscopies), prostate cancer, and lung cancer screenings.

Heart Disease Screenings:

This includes screenings for abdominal aortic aneurysms and cardiovascular disease, as well as intensive behavioral therapy for cardiovascular disease.

Sexually Transmitted Infections:

Medicare covers screening for chlamydia, gonorrhea, syphilis, and hepatitis B for those at risk.

Vaccinations:

Free vaccinations are available for COVID-19, hepatitis B, influenza, and pneumonia.

Annual Wellness Visit (AWV):

This is a one-on-one visit with your doctor to develop or update your personalized prevention plan, which is also free.

Other Free Screenings:

Medicare also covers free screenings for alcohol misuse, depression, diabetes, hepatitis C, HIV, osteoporosis, and more.

Answer: Medicare generally covers routine costs associated with participation in qualifying clinical trials. This includes costs like hospitalization, outpatient services, & medical care for treatment-related side effects, if these are things Medicare would normally cover. However, Medicare doesn't typically cover the experimental treatment or drug itself, or costs specifically related to the clinical trial research.

Here's a more detailed breakdown:

What Medicare Does Cover:

Routine costs:

This includes the costs of services & procedures that would be covered by Medicare if the patient weren't participating in a clinical trial.

Medical care for treatment-related side effects:

Medicare will cover medical care needed to address complications or side effects arising from participating in the clinical trial.

Some costs related to investigational devices:

Medicare may cover costs related to investigational devices if certain conditions are met.

Coverage with conditions:

In specific instances, Medicare may reimburse for investigational treatments under certain conditions, notes the National Institutes of Health (NIH).

What Medicare Does Not Cover:

Experimental treatment costs:

Medicare typically doesn't cover the cost of the experimental drug, device, or treatment itself, or the costs associated with the research aspect of the trial.

Costs not covered by Medicare otherwise:

If a cost is not covered by Medicare outside of a clinical trial, it is unlikely to be covered as part of the trial.

Important Considerations:

Clinical trial must meet requirements: The clinical trial must meet specific criteria & have therapeutic intent to be covered by Medicare.

Prior authorization may be needed: Some Medicare plans may require prior authorization for certain clinical trial costs.

Patient cost-sharing: Even with Medicare coverage, patients may still have out-of-pocket costs for co-insurance and deductibles.

Discussions with plan administrator to understand what is & isn't covered.

Answer: No, Medicare does not cover stairlifts or most other home modifications, even if they are needed for safety reasons. Medicare generally considers these items as non-covered modifications, not durable medical equipment. However, some Medicare Advantage plans may offer supplemental benefits that could cover stairlifts, and there are other potential funding sources like Medicaid waivers or veterans' benefits.

Elaboration:

Medicare's Coverage:

Medicare Part B, which covers durable medical equipment, generally does not cover stairlifts or other home modifications, as they are not considered durable medical equipment.

Medicare Advantage Plans:.

Some Medicare Advantage plans (private plans that contract with Medicare) may offer supplemental benefits that could include coverage for stairlifts or other home modifications. However, coverage varies significantly from plan to plan, so it's essential to check with your specific provider to see if they offer this benefit, according to optionshme.com.

Medicaid and Waivers:

Medicaid, a state-run program for low-income individuals, may provide funding for home modifications through Home and Community-Based Services (HCBS) waivers. These waivers allow states to tailor programs to their specific needs and may cover items like stairlifts if they help individuals stay in their homes.

Veterans' Benefits:

Veterans may be eligible for financial assistance from the Department of Veterans Affairs (VA) for home modifications through programs like the Home Improvements and Structural Alterations (HISA) grant.

Other Funding Sources:

In addition to Medicaid and VA benefits, other funding sources for home modifications may include state and local programs, nonprofit organizations, or private financing options.

Answer: To choose the right healthcare company and representative, research their reputation, verify credentials, consider accessibility and communication style, and ask for recommendations. For a healthcare representative, ensure they are trustworthy, comfortable with discussions about healthcare wishes, and will honor your decisions.

Answer: Medicare generally doesn't cover 24/7 in-home care for dementia patients who wander or need constant supervision, but it can cover part-time, intermittent care for those who are "homebound" and need skilled nursing or therapy. This means Medicare Part A may cover up to 35 hours per week of home health services, but not 24-hour-a-day care.

Answer: Yes, Medicare can cover certain wearable medical devices for chronic conditions like insulin pumps and continuous glucose monitors (CGMs) under Part B as durable medical equipment (DME) if they are deemed medically necessary and prescribed by a healthcare professional. However, coverage may vary depending on the specific device and individual circumstances.

Answer: Yes, Medicare can cover bariatric surgery for those with severe obesity, but it generally does not cover weight-loss programs or medications for obesity alone. Bariatric surgery may be covered if your BMI is 35 or higher and you have a co-morbid condition related to obesity, and if you've previously tried and failed medical treatment for obesity.

Answer: Coverage:

Medicare Part B covers IOPs for mental health, substance use disorders, or co-occurring disorders. This includes services like individual and group therapy, occupational therapy, and medication management.

Cost-Sharing:

After meeting the Part B deductible, beneficiaries pay a percentage (coinsurance) of the Medicare-approved amount for each day of intensive outpatient services.

Location:

IOPs can be received at hospitals, community mental health centers, Federally Qualified Health Centers, Rural Health Clinics, or Opioid Treatment Programs.

Requirements:

While partial hospitalization requires a doctor's certification that inpatient treatment would otherwise be needed, IOP services don't require this certification if the individual needs a minimum of nine hours per week of intensive outpatient care.

Services:

These programs can include individual and group therapy, medication management, activity therapies, and family counseling.

Telehealth:

Medicare also covers telehealth services for mental health and substance use disorders, allowing for treatment at any location in the US, including at home.

Answer: Medicare and Medicaid do not cover medical marijuana as a treatment option because marijuana is classified as a Schedule I Drug and it's not FDA-approved.

Answer: Original Medicare:

Telehealth is covered:

Medicare has expanded telehealth coverage for mental health, including services like virtual therapy, under certain conditions.

Specific conditions:

Beneficiaries must have seen their mental health provider in person within the six months prior to their first telehealth appointment and at least yearly thereafter.

Provider requirements:

The provider must be enrolled in Medicare and the service must be deemed medically necessary.

Coverage for specific apps:

Medicare may not cover specific mental health apps outright, but it may cover services delivered through these apps if the services are provided by a Medicare-enrolled provider.

Medicare Advantage Plans:

Medicare Advantage plans may offer additional benefits:

.

These plans can choose to cover mental health services, including telehealth, beyond what is covered by Original Medicare.

Plan-specific benefits:

.

Beneficiaries with Medicare Advantage plans should check with their specific plan to understand their telehealth coverage and what mental health apps or platforms are included.

Supplemental benefits:

.

Medicare Advantage plans may also offer supplemental benefits for mental health that are not covered by Original Medicare.

Additional Considerations:

Provider-specific:

Even if a mental health app or platform is covered, the specific provider using it must be a Medicare-enrolled provider.

Medically necessary:

The services provided must be deemed medically necessary by the provider to be covered.

Depression screening:

Medicare covers one depression screening per year, which can be a helpful first step for individuals seeking mental health support.

In summary, while Medicare generally covers mental health services, including telehealth, it's crucial to understand the specific coverage options available under Original Medicare or a Medicare Advantage plan, and to ensure that the services provided by a Medicare-enrolled provider are deemed medically necessary.

Answer: Yes, you can switch from a Medicare Advantage plan to Original Medicare with a Medigap plan mid-year if you're diagnosed with a serious illness. However, it's important to understand the timing and enrollment periods that apply.

Elaboration:

Special Enrollment Periods:

.

A serious illness diagnosis can qualify you for a Special Enrollment Period, allowing you to switch outside the normal open enrollment periods.

Medicare Advantage Open Enrollment:

.

If you are already enrolled in a Medicare Advantage plan, you can switch to Original Medicare during the Medicare Advantage Open Enrollment Period (January 1 to March 31).

Annual Enrollment Period:

.

You can also switch during the Annual Enrollment Period (October 15 to December 7).

Medigap Enrollment:

.

Switching from Medicare Advantage to Original Medicare also gives you an opportunity to enroll in a Medigap plan, which can help cover the cost-sharing requirements of Original Medicare.

Guaranteed Issue Rights:

.

If you disenroll from a Medicare Advantage plan during your first year, you have guaranteed issue rights to a Medigap policy, meaning an insurer cannot deny you coverage or charge you a higher premium.

Guaranteed Issue Rights in Other Situations:

.

You also have guaranteed issue rights to a Medigap policy if your Medicare Advantage plan terminates or if you move outside the plan's service area.

Contact Medicare:

.

For more specific information about your eligibility and the process for switching, it's recommended to contact Medicare.

Answer: Here's a detailed breakdown:

Medically Necessary:

Medicare will only cover occupational therapy if it's considered medically necessary to help you improve or maintain your ability to perform activities of daily living.

Doctor's Certification:

You'll need a doctor or other healthcare provider to certify that you need occupational therapy and to develop a treatment plan.

Outpatient Setting:

The therapy must be provided in an outpatient setting, like a clinic or therapy center, and not as an inpatient service.

Provider Acceptance:

The occupational therapy provider must accept Medicare assignment, which means they agree to bill Medicare directly and accept the Medicare-approved amount as payment in full.

Deductible and Coinsurance:

You'll need to pay your Part B deductible before Medicare starts paying, and then you'll pay 20% of the Medicare-approved amount for each session.

No Limits:

There is no limit on how many sessions or how much Medicare will pay for medically necessary occupational therapy in a calendar year.

Annual Threshold:

In 2025, Original Medicare covers up to $2,410 for combined physical therapy and speech-language pathology (SLP) services, and $2,410 for OT alone. However, there is no limit on the amount Medicare pays for medically necessary services.

Answer: Yes, even if you live abroad, you are generally still required to pay Medicare premiums. However, you are not required to enroll in Medicare if you live outside the U.S. for at least 30 consecutive days. If you choose to enroll in Medicare while living abroad, you will still need to pay the premiums, but you won't be able to access the benefits unless you return to the U.S.

Answer: A common deceptive marketing trick used in Medicare Advantage plans involves falsely assuring beneficiaries that their preferred doctors are in-network, even if they are not. This trick hides the restrictive networks that Medicare Advantage plans often have, leading to unexpected out-of-pocket costs when beneficiaries try to see their regular doctors.

Here's a more detailed explanation:

Misleading Network Information:

Insurance agents may exaggerate the network of doctors a plan includes, falsely stating that a beneficiary's current doctor is in-network.

Failure to Check Network:

Some agents may not verify the network status of a beneficiary's doctors before enrolling them in a plan, according to Medicare Agents Hub.

Deceptive Marketing Materials:

Mailers and advertisements can be designed to resemble official government communications, making it harder for beneficiaries to distinguish between official information and marketing materials.

Financial Disappointment:

When beneficiaries switch to a Medicare Advantage plan and discover their doctor is not in-network, they face the unexpected cost of paying out-of-pocket for those services.

Limited Access to Specialists:

Medicare Advantage plans may have limited access to certain specialists, such as dermatologists or cardiologists, compared to Original Medicare.

Answer: If you have Original Medicare, you have coverage anywhere in the U.S. and its territories. This includes all 50 states, the District of Columbia, Puerto Rico, the Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. Most doctors and hospitals take Original Medicare.

Answer: Key Takeaways:

- Medicare Advantage offers extra benefits, but out-of-network care may be limited or costly.

- Other disadvantages include difficulty switching out of the plans later, restrictions on care access, and limitations on extra benefits.

- Geographical restrictions also mean you cannot access care if you travel out of state unless you have an emergency or need dialysis.

- Medicare Advantage plans can change benefits annually or drop providers mid-year.

- MA plans could be a fit for people on a tight budget or who would qualify for a special needs plan.

Answer: Medicare generally covers palliative care for serious illnesses through Part B, while hospice care is covered under Part A. Palliative care focuses on improving quality of life for individuals with serious illnesses, and it can be received alongside curative treatments. Hospice care is a specialized type of palliative care for individuals with a life expectancy of six months or less who are no longer pursuing curative treatment.

Palliative Care:

Coverage: Medicare Part B typically covers palliative care services.

Focus: Improving quality of life and managing symptoms for patients with serious illnesses.

Timing: Can be received at any point during a serious illness, alongside or before hospice care.

Eligibility: No specific life expectancy requirement.

Hospice Care:

Coverage:

Medicare Part A covers hospice care.

Focus:

Comfort and support for terminally ill patients who are not pursuing curative treatment.

Timing:

Typically initiated when a patient's life expectancy is six months or less.

Eligibility:

Requires a physician to certify that the patient is terminally ill with a life expectancy of six months or less.

Answer: I once had a customer who was extremely upset about an issue with their plan. I listened attentively to their concerns and apologized for any inconvenience. Then, I offered them a thorough explanation of all parameters of their current plan, for which they were greatful.

Answer: To determine if a Medicare agent is legitimate, verify their license and certifications with your state's insurance department and the Centers for Medicare & Medicaid Services (CMS). Look for independent brokers who can compare multiple plans and avoid agents who push specific plans or offer excessive incentives.

Key points to look for in a legitimate Medicare agent:

License and Certification:

All Medicare agents must be licensed in the state where they sell plans and certified by the insurance companies they represent.

Independent Broker:

Independent brokers can offer plans from multiple companies, providing a broader range of options.

No Sales Pressure:

A legitimate agent will educate you about your options and won't pressure you to choose a particular plan.

Specialized Knowledge:

Look for agents who specialize in Medicare and understand the nuances of different plans.

Avoid Excessive Incentives:

Legitimate agents should not offer gifts, free meals, or cash incentives to enroll in a plan.

No Door-Knocking or Unsolicited Calls:

Legitimate agents will not visit your home uninvited or make unsolicited phone calls.

Be Skeptical of Vague Answers:

If an agent gives vague answers or avoids providing specific details about coverage, it's a red flag.

Check Reviews and References:

Look for online reviews or ask for client references to gauge the agent's reputation and experience.

Report Suspicious Activity:

If you encounter any unethical behavior or suspected scams, report it to the CMS and the FTC.

Answer: If you initially enter a skilled nursing facility for rehabilitation under Medicare Part A, and then your needs transition to requiring long-term care, your Medicare coverage will likely end after the 100-day benefit period, unless other specific conditions are met. Medicare generally does not cover long-term care needs, such as custodial care or chronic care, in a skilled nursing facility.

Here's a more detailed breakdown:

Initial Medicare Coverage:

Part A:

Medicare Part A can cover up to 100 days of skilled nursing facility care in a benefit period, provided you meet certain criteria, including having a 3-day hospital stay prior to the SNF stay.

100-Day Benefit:

Medicare will generally cover the first 20 days with no copay, and then a coinsurance amount (currently $209.50 per day in 2025) for days 21-100.

Intensive Rehabilitation:

The coverage is intended for intensive rehabilitation and medical supervision, not for chronic or custodial care.

Transition to Long-Term Care:

Medicare Coverage Ends:

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If your condition requires long-term care beyond the 100-day benefit period, Medicare coverage will typically stop.

Out-of-Pocket Costs:

.

You will be responsible for the cost of care in the SNF after the 100-day limit.

Medigap and Medicare Advantage:

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Medigap policies can help cover out-of-pocket costs for Part A, but not if you're on a Medicare Advantage plan.

Options for Long-Term Care:

Medicaid:

You may be eligible for long-term care through Medicaid, which has different eligibility requirements and coverage.

Private Long-Term Care Insurance:

Consider private insurance policies to help cover the costs of long-term care.

Other Programs:

Explore other public and private programs that may offer financial assistance for skilled nursing facility costs, such as PACE programs.

Answer: Medicare doesn't cover the costs of long-term custodial care in nursing homes or assisted living facilities. To plan for these costs, you'll need to consider options like LTC insurance, savings & potentially qualifying for Medicaid.

Here are options on how to plan for these costs:

Long-Term Care Insurance:

This type of insurance can help cover the costs of custodial care in a nursing home or assisted living facility, or for in-home care. You'll typically need to qualify for a payout, often requiring assistance with at least two activities of daily living or evidence of cognitive impairment.

Private Pay:

Many individuals and families pay for long-term care out of pocket, using savings, investments, or even selling assets like property. Be aware that using up these resources may eventually make Medicaid an option.

Medicaid:

This program, funded by the federal government but administered by individual states, provides coverage for long-term care, including nursing home care, for people with low incomes & limited assets. Eligibility requirements vary by state but typically involve strict income & asset limits.

Savings & Investments:

Building a dedicated fund for LTC expenses through consistent saving & strategic investing can help offset future costs.

Health Savings Accounts (HSAs):

If you have a high-deductible health insurance plan, funding a HSA can be a way to save for long-term care expenses & potentially minimize the tax bite.

Consider Alternate LTC Options:.

The National Council on Aging (NCOA) suggests exploring options like community-based care services, subsidized senior housing, & Continuing Care Retirement Communities (CCRCs).

Important Considerations:

Medicare Supplement: While Med Supp plans (Medigap) can help cover some costs associated with Original Medicare they don't cover LTC or care lasting more than 100 days.

Medicare Advantage: Medicare Advantage plans may help cover some LTC costs but coverage costs can vary significantly between plans.

Answer: What Medicare Does Cover in a CCRC:

Skilled Nursing Care: Medicare may cover medically necessary skilled nursing care in a CCRC's healthcare center, especially if it's a short-term stay following a hospital stay.

Physician Services: Medicare covers doctor visits and other medically necessary services provided within the CCRC.

Hospital Stays: If a resident needs to be hospitalized, Medicare can cover those costs.

Medical Supplies: Medicare may cover the cost of certain medical supplies, like wheelchairs or walkers, if a resident needs them.

What Medicare Does Not Cover in a CCRC:

Room and Board: Medicare does not cover the cost of housing, meals, or non-medical care in the CCRC.

Assisted Living Services: Medicare does not cover services like bathing, dressing, or transferring, which are typically part of assisted living.

Long-Term Nursing Home Care: While Medicare may cover short-term skilled nursing care, it generally doesn't cover long-term stays in a CCRC's nursing home unit.

Factors to Consider:

CCRC Contract: The type of residency contract you have with the CCRC will impact how costs are handled when skilled nursing care is needed.

Long-Term Care Insurance: You may have long-term care insurance that can help cover costs beyond what Medicare covers.

Medicaid: Medicaid may be an option for low-income individuals who qualify for long-term care.

Medicare Part A and Part B: Medicare Part A covers hospitalization and skilled nursing care, while Part B covers doctor visits and outpatient care.

Medicare Advantage: Medicare Advantage plans may offer additional benefits, but they still generally don't cover long-term care expenses.

Answer: The new $2,000 out-of-pocket maximum for drug costs, part of the Inflation Reduction Act, is crucial for Medicare beneficiaries because it limits their annual spending on prescription drugs covered by Part D plans. This cap protects individuals, particularly those with high drug costs, from facing potentially crippling expenses.

Here's why it's significant:

Financial Protection: The cap ensures that beneficiaries don't spend more than $2,000 out-of-pocket on covered medications within a year.

Access to Medications: By limiting out-of-pocket costs, the cap helps ensure that individuals can afford the medications they need, regardless of their income level.

Improved Financial Stability: The cap can free up financial resources that might otherwise be spent on high drug costs, allowing beneficiaries to invest in other areas of their lives or save for the future.

Targeted Savings: The cap is particularly beneficial for those taking high-cost medications for conditions like cancer, rheumatoid arthritis, and other serious illnesses.

Simplified Cost Management: The cap makes it easier for individuals to understand and manage their healthcare expenses, as they know their maximum annual out-of-pocket cost for Part D drugs.

A More Equitable System: The cap helps create a more equitable system by preventing disproportionate spending burdens for those with high drug costs.

Answer: To save money on your Med Supp (Medigap) insurance, consider enrolling during your OEP, choosing a plan with lower premiums or a higher deductible, & comparing quotes from different insurance companies. You can also inquire about discounts & explore Medicare SELECT plans, which offer lower premiums but have restrictions on covered providers. Here's a more detailed breakdown:

1. Enroll During Open Enrollment: Med Supp OE is a six-month period that starts on the first day of the month you are eligible for Medicare Part B. Enrolling during this period ensures you won't be charged a penalty for not having a Medigap plan. You can also enroll during Guaranteed Issue Rights, which occur when certain life circumstances, like losing coverage due to a change in service area, occur.

2. Compare Premiums & Plans: Shop around for Medigap plans from different insurance companies. Consider switching to a company that offers lower premiums for your current plan.

Explore different Medicare Supplement plan letters, like Plan G, Plan N, or plans with high deductibles, as they may have lower premiums.

3. High-Deductible Plans: High-deductible plans, like Plan G, may have lower premiums than standard plans, but your out-of-pocket costs will be higher when you use them.

4. Medicare SELECT: Medicare SELECT plans offer lower premiums but require you to use doctors & hospitals w/in their network. If you're comfortable with the restrictions, a Medicare SELECT plan could save you money.

5. Discounts & Cost-Saving Programs: Inquire about discounts offered by your insurance company, such as discounts for being married, non-smokers, or paying annually.

Explore Medicare Savings Programs, which are run by your state & can help with the cost of Medicare. Contact your State Health Insurance Assistance Program (SHIP) for help finding cost-saving programs & guidance on Medicare Supplement plans.

6. Make sure the plan you choose meets your specific health needs & budget.

Answer: Medicare Part B covers a wide range of medical services, including doctor's visits, outpatient care, and some preventive services. However, it's not a comprehensive plan on its own and doesn't cover everything. It's generally recommended to have both Part A and Part B for more complete coverage, says mutualofomaha.com.

What Part B Covers:

Outpatient Care: According to ehealthinsurance.com This includes visits to doctors' offices, outpatient surgeries, and other services not requiring an overnight stay.

Preventive Services: GoodRx.com notes This includes screenings for certain diseases, immunizations, and a "Welcome to Medicare" visit.

Durable Medical Equipment: As stated by healthline.com This includes items like wheelchairs, walkers, and oxygen equipment.

Mental Health & Substance Use Disorder Care: Says medicare.gov

Ambulance Services: Medicare.gov states

Some Outpatient Prescription Drugs: Medicare.gov notes

Limited Home Health Care: According to healthline.com

What Part B Doesn't Cover:

Inpatient Hospital Stays: eHealth.com states

Skilled Nursing Facility Care: According to Humana.com

Most Prescription Drugs: Notes eHealth.com

Vision, Dental, and Hearing Services: Humana.com notes

Routine Physical Exams: Humana.com states

Cosmetic Surgery: Humana.com notes

Is it Enough?

Part B alone is often not sufficient for comprehensive healthcare coverage. While it covers many essential services, it has limitations and doesn't cover all potential needs. Medicare Part A, which covers hospital and skilled nursing facility care, is essential to round out coverage. Many people also choose Medicare Advantage plans (Part C) which often offer additional benefits like vision, dental, and hearing coverage,

Answer: Medicare Savings Programs (MSPs) help individuals with limited income and resources pay for Medicare costs, including premiums, deductibles, coinsurance, copayments, and prescription drug expenses. These programs, also known as Medicare Buy-In Programs or Medicare Premium Payment Programs, are designed to alleviate the financial burden of Medicare for those who need it.

Here's how they work:

They cover premiums: MSPs help cover the monthly Part A and/or Part B premiums, depending on the specific program.

They reduce out-of-pocket costs: They may help pay for deductibles, coinsurance, and copayments for Medicare-covered services.

They help with prescription drug costs: MSPs often automatically qualify individuals for Extra Help, a program that assists with Medicare Part D (prescription drug) costs.

They can help with extra expenses:

In some cases, MSPs can also help with other health-related expenses beyond standard Medicare costs, such as vision or dental care.

Types of Medicare Savings Programs:

Qualified Medicare Beneficiary (QMB): Helps with Part A and Part B premiums, deductibles, coinsurance, and copayments.

Specified Low-Income Medicare Beneficiary (SLMB): Helps with Part B premiums and automatically qualifies for Extra Help.

Qualifying Individual (QI): Helps with Part B premiums and automatically qualifies for Extra Help.

Eligibility:

Eligibility for MSPs is determined by income and resources, and each program has specific thresholds. The specific requirements vary by state and can be found on the Medicare website or by contacting your local Medicaid office.

In summary: Medicare Savings Programs are designed to make Medicare more affordable for low-income individuals by helping them with premiums, out-of-pocket costs, and prescription drug expenses, according to the Social Security Administration.

Answer: Working with a Medicare agent can be beneficial because they can help you navigate the complexities of Medicare, compare plan & find the best coverage for your needs. They offer personalized guidance, understand local healthcare landscapes, & provide ongoing support, ultimately helping you make informed decisions & save time & money. Here's a more detailed look at the reasons:

1. Expertise and Knowledge: Medicare agents have in-depth knowledge of various Medicare plans, including Original Medicare (Part A & B), Medicare Advantage plans (Part C), & Med Supp policies (Medigap). They are familiar with the local healthcare landscape, including local providers, hospitals & network coverage. They stay updated on changes in Medicare regulations & policies.

2. Personalized Guidance: Medicare agents understand your unique health needs, budget, & preferences. They can help you compare plan options, weigh the pros & cons, & choose the coverage that best suits your situation. They can answer your questions & provide clarification on any aspect of your Medicare coverage.

3. Time & Effort Savings: Navigating Medicare can be time-consuming & overwhelming.

Medicare agents can do the research for you, saving you time & effort. They can help you enroll in the plan of your choice & handle the paperwork.

4. Ongoing Support: Medicare agents are available to answer your questions & provide ongoing support, even after you enroll in a plan. They can help you understand your benefits, file claims, & navigate any issues that may arise. They can help you switch plans during open enrollment or if your needs change.

5. Potential Cost Savings: While agents may receive commissions from insurance companies, their services are typically free to you. They can help you find the most cost-effective plan for your needs, potentially saving you money.

6. Advocate for Your Interests: Medicare agents work in your best interest, helping you find the best coverage & advocate for your needs

Answer: There is no single "better" option between Original Medicare & Medicare Advantage; the best choice depends on individual needs & preferences. Original Medicare offers broader access to providers & no network restrictions, while Medicare Advantage plans can provide additional benefits, lower costs, & potentially more coordinated care.

Original Medicare:

Pros:

Access to any doctor or specialist who accepts Medicare nationwide.

No need for prior authorization for most services.

Ability to add a Medigap policy to supplement coverage & reduce out-of-pocket costs.

No network restrictions.

Cons:

May have higher out-of-pocket costs without a Medigap policy.

Does not include prescription drug coverage, requiring a separate Part D plan.

Does not cover additional benefits like vision, dental, or hearing.

Medicare Advantage:

Pros:

Often includes prescription drug coverage (Part D).

May include additional benefits like vision, dental, & hearing coverage.

May have lower copayments for some services.

May have an out-of-pocket maximum, limiting potential costs.

May offer more coordinated care and a primary care physician as a gatekeeper.

Cons:

May limit choices to a network of doctors & hospitals.

May require prior authorization for certain services.

Additional benefits & costs can vary significantly between plans.

Out-of-network care may be limited or more expensive.

Recommendation:

Choose Original Medicare if: You prioritize broad access to providers, don't need additional benefits like vision or dental, & are comfortable managing your own out-of-pocket costs (potentially with a Medigap policy).

Choose Medicare Advantage if: You prefer the convenience of a single plan that includes prescription drug coverage & additional benefits, are comfortable with network restrictions, & want to limit potential out-of-pocket costs.

Ultimately, the best choice depends on your individual health status, financial situation, & preferences for managing your healthcare.

Answer: Standalone Part D Plans:

Flexibility: You can generally choose any pharmacy that participates in the plan, & you're not limited to a specific provider network.

Coverage: Part D plans cover a wide range of diabetes medications, including insulin & other oral medications.

Formulary: While Part D plans have formularies (lists of covered drugs), they may be more flexible than some Medicare Advantage plans.

Prior Authorization: Some Part D plans may require prior authorization for certain medications, but this is less common than in Medicare Advantage plans.

Cost: Part D plans can vary in price, so it's important to compare premiums & copays.

Special Considerations: The Inflation Reduction Act significantly reduced the cost of insulin, limiting out-of-pocket costs to $35 per month. If you have limited income & resources, you may be eligible for Extra Help to lower your drug costs. You can also explore patient assistance programs offered by pharmaceutical companies.

Medicare Advantage Plans (MA-PDs):

Comprehensive Coverage: MA-PDs typically offer all the benefits of Original Medicare (Parts A and B) plus drug coverage (Part D).

Provider Networks: MA-PDs often have specific provider networks, which may limit your choice of doctors & pharmacies.

Prior Authorization: Some MA-PDs may require prior authorization for certain medications, even if they are on the formulary.

Cost: MA-PDs can have lower premiums than standalone Part D plans, but copays & deductibles may vary.

Coordination of Care: MA-PDs may offer additional services like preventive care & chronic disease management, which can be helpful for people with diabetes.

Special Considerations: MA-PDs may have more strict rules about which medications are covered, & it's important to check the formulary. You may also need to obtain a prescription for any medications from your primary care physician. Some diabetes-related supplies like syringes, gauze & alcohol may also be covered by MA-PDs.

Answer: Yes, there is a strong argument that Medicare should do more to address health disparities among minority seniors. Research suggests that expanding Medicare, particularly for those under 65, could significantly reduce these disparities. Additionally, Medicare's significant influence as a major purchaser & regulator of healthcare provides opportunities for systemic change to improve access & quality of care for minority beneficiaries.

Why Addressing Disparities is Important:

Unequal Outcomes: Minority seniors often experience higher rates of chronic diseases, poorer health status, & lower rates of preventative care compared to their white counterparts.

Structural Factors: These disparities are often linked to social determinants of health like poverty, discrimination, & limited access to quality healthcare, education, & resources.

Financial Strain: Many minority seniors are more likely to rely on Medicaid or less adequate supplemental coverage, putting a greater financial strain on their health care.

Increased Costs: Health disparities lead to higher overall healthcare costs, including those associated with emergency room visits & chronic disease management.

How Medicare Can Help:

Expanded Coverage: Lowering the eligibility age for Medicare could significantly expand access to healthcare for minority seniors, particularly in areas with high rates of disparity.

Targeted Programs: Medicare can create specific programs and initiatives to address the unique needs of minority seniors, such as:

Language access: Ensuring healthcare providers have the ability to communicate effectively with beneficiaries who speak languages other than English.

Cultural competency training: Educating healthcare professionals on the specific cultural & social factors that may affect health outcomes for minority seniors.

Transportation & childcare: Providing assistance with transportation to appointments & childcare services, which can be significant barriers to care.

Answer: One of the most rewarding aspects of working with Medicare clients is the opportunity to make a tangible difference in their lives by helping them navigate a complex and often daunting healthcare system. This involves educating them about their options, clarifying their coverage, and ensuring they feel confident in their decisions. The satisfaction comes from seeing the relief and peace of mind that comes from having secure healthcare coverage.

Answer: One outdated and potentially unfair Medicare regulation is the "Improvement Standard" that some argue inappropriately limits coverage for skilled nursing home care when no improvement is expected. This standard suggests that Medicare may not cover care for conditions where no improvement is possible, even if the care is essential for maintaining or preventing deterioration. Here's why this is a problem:

Focus on "improvement" over maintenance: The standard focuses on whether a patient can improve, rather than whether they require skilled care to prevent or slow decline, according to the Center for Medicare Advocacy.

Limited access to necessary care: This can deny individuals the care they need to manage chronic conditions and maintain their quality of life, notes the Center for Medicare Advocacy.

Disproportionate impact: This can disproportionately affect individuals with progressive illnesses or those who are near the end of life, notes the Center for Medicare Advocacy.

While the Medicare program acknowledges the need for skilled care for maintenance purposes, some argue that the "Improvement Standard" interpretation by some providers or insurers may not fully reflect this principle.

Answer: To obtain dental and vision coverage with Medicare, you'll need to enroll in a Medicare Advantage (Part C) plan, as Original Medicare (Parts A & B) does not cover these services. These plans, offered by private insurance companies, often include dental, vision, and hearing coverage, along with other extras not covered by Original Medicare.

Here's how to get dental and vision coverage:

1. Choose a Medicare Advantage Plan:

.

Medicare Advantage plans are an alternative to Original Medicare and are offered by private insurance companies approved by the government.

2. Review Plan Details:

.

Carefully examine the specific benefits of each plan to ensure it includes the dental and vision coverage you need, including the types of services and any limits on coverage.

3. Enroll in Your Chosen Plan:

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Once you've selected a plan, you can enroll through the CMS Online Enrollment Center or by contacting the plan provider.

Answer: The reason for the difference in benefits like SilverSneakers is that while Original Medicare (Parts A and B) doesn't include fitness programs, Medicare Advantage plans (Part C) often do. Your friend likely has a Medicare Advantage plan that includes SilverSneakers, while you may have Original Medicare or a different plan that doesn't offer this benefit.

Here's a more detailed explanation:

Original Medicare:

This is the basic Medicare coverage, and it doesn't include fitness programs like SilverSneakers.

Medicare Advantage:

These are plans offered by private insurance companies that must cover all of Original Medicare's benefits, but can also include extra benefits like fitness programs, gym memberships, and more.

Medicare Supplement (Medigap):

These plans help pay for some of the costs of Original Medicare, but they don't generally include fitness programs like SilverSneakers.

SilverSneakers:

This is a fitness program offered by many Medicare Advantage plans, giving members access to gyms and other fitness facilities.

To understand why you don't have SilverSneakers while your friend does, consider these factors:

Plan Type:

You likely have Original Medicare or a Medicare Supplement, neither of which include fitness programs.

Plan Specifics:

Even within Medicare Advantage plans, the specific benefits offered can vary. Some plans may include SilverSneakers, while others may not.

If you'd like to access SilverSneakers, you have a few options:

1. Consider a Medicare Advantage plan:

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Check which plans in your area offer SilverSneakers as a benefit and enroll during the Annual Election Period (October 15 - December 7).

2. Contact your insurance provider:

.

Ask them about the benefits of your current plan and whether they offer any fitness programs.

3. Evaluate your fitness needs:

.

If a gym membership is important to you, you may need to pay for it out-of-pocket or explore other fitness options.

Answer: The Maximum Out-of-Pocket (MOOP) limit in Medicare Advantage (Part C) plans is an annual cap on how much you pay for covered services, excluding premiums. It protects you from excessive healthcare costs, ensuring you don't spend more than a set amount on deductibles, copayments, and coinsurance.

Elaboration:

What it is:

The MOOP is a yearly limit on your out-of-pocket expenses for covered services in Medicare Advantage plans.

What it covers:

It applies to deductible, copay, and coinsurance costs for in-network and, in some cases, out-of-network services.

How it works:

Once you reach your MOOP, your plan pays 100% of the remaining covered expenses for the rest of the year.

What it doesn't cover:

It doesn't cover monthly premiums, charges for non-covered services, or costs above the Medicare-allowed amount.

Annual Limit:

The MOOP for Medicare Advantage plans is set annually by the government, and for 2025, it is $9,350. However, individual plans can set lower limits, according to Medical News Today and the National Council on Aging (NCOA).

PPO plans:

PPO plans may have higher MOOP limits that also include out-of-network services.

Answer: Whether you can keep your current doctors depends on whether they are in the network of your new Medicare Advantage plan. With Original Medicare, you can see any doctor who accepts Medicare. However, with Medicare Advantage plans, you're typically limited to doctors within the plan's network.

Elaboration:

Original Medicare:

If you have Original Medicare (Parts A and B), you can see any doctor who accepts Medicare.

Medicare Advantage Plans:

With Medicare Advantage plans (Part C), you're generally restricted to doctors who are in the plan's network.

Checking Your Doctor's Network:

Before switching to a Medicare Advantage plan, it's crucial to confirm if your current doctors are in the network of the plan you're considering. You can do this by checking the plan's website or contacting the plan's member services.

Switching if Necessary:

If your doctor is not in the network, you may need to find a new doctor within the plan's network. You can use the plan's online directory or contact member services for assistance in finding a new doctor.

Answer: One crucial piece of advice for seniors selecting a Medicare plan is to thoroughly review the plan's formulary (list of covered medications) and ensure it includes all their regularly prescribed medications. This prevents potential coverage gaps and costly surprises down the road.

Elaboration:

Understanding Formularies:

A formulary is a list of prescription drugs covered by a particular Medicare Part D plan (or Medicare Advantage plan with drug coverage). It's essentially a "drug list" that dictates which medications the plan will pay for.

Importance for Seniors:

Seniors often take multiple medications for various health conditions, so it's crucial to verify that their specific medications are on the plan's formulary.

Potential Problems:

If a medication isn't covered, seniors may have to pay the full cost of the drug, switch to an alternative, or even face difficulty accessing necessary treatment.

Prioritizing Medication Coverage:

Seniors should prioritize finding a plan that covers their medications, even if other factors like premiums or benefits are slightly less favorable.

Using Formulary Resources:

Medicare's website and the plan's website often provide downloadable formularies or online search tools to help seniors check for coverage.

Seeking Assistance:

If seniors have questions about their medication coverage or need help finding a plan that meets their needs, they can consult with a Medicare counselor or a qualified insurance agent.

Answer: It is possible for a doctor to leave a Medicare Advantage plan's network, even if they were previously listed as in-network. This can happen because Medicare Advantage plans contract with providers, and these contracts can be terminated or not renewed, leading to a provider dropping out of the network. Here's a more detailed explanation:

Contracts with Providers:

Medicare Advantage plans establish agreements with healthcare providers, but these agreements are not necessarily permanent.

Provider Decisions:

Doctors or other providers can decide not to renew their contracts with a specific plan, or the plan may choose to remove them during a network review.

Changes in Network:

Provider networks can change at any time during the year, and you may be notified by your plan if significant changes occur.

Impact on Your Care:

If a provider leaves the network, you may need to find a new in-network doctor to continue receiving care covered by your plan

Answer: Medicare generally doesn't cover healthcare services received on a cruise ship if it's more than six hours away from a U.S. port. However, if the ship is within U.S. territorial waters (i.e., within a U.S. port or within six hours of arrival/departure), Medicare may cover medically necessary services. The doctor also needs to be authorized to provide medical services on the ship.

Here's a more detailed breakdown:

Within U.S. Territorial Waters:

If the cruise ship is within U.S. territorial waters (in a U.S. port or within six hours of arrival/departure), Medicare may cover medically necessary services.

Outside U.S. Territorial Waters:

Medicare generally does not cover healthcare services when the ship is more than six hours away from a U.S. port.

Doctor's Authorization:

The doctor providing the services on the cruise ship needs to be legally authorized to do so.

Claim Submission:

If you receive medical services on a cruise ship and the doctor's office is in the U.S., they will submit the claim to Medicare. If the doctor's office is not in the U.S., you'll need to complete a CMS-1490S form and submit it to Medicare with the necessary documentation.

Medicare Advantage Plans:

Some Medicare Advantage plans may offer additional coverage for international travel, including on cruise ships, so it's important to check with your plan provider.

Answer: To effectively educate clients new to Medicare, start by breaking down the system into manageable parts, focusing on plain language & avoiding jargon. Emphasize the different parts of Medicare (A, B, C, and D), & then delve into Medicare Advantage & Medigap plans. Encourage clients to assess their healthcare costs & needs, & guide them through enrollment using resources like the Medicare.gov website & the AARP website. Here's a more detailed approach:

1. Understanding the Basics: Medicare Part A (Hospital Insurance): Explain that this part covers hospital stays, skilled nursing facilities, and some home healthcare. Medicare Part B (Medical Insurance): Outline that this covers doctor's visits, outpatient care, and preventive services. Medicare Part C (Medicare Advantage): Explain that this is an alternative to Original Medicare (Parts A and B) and offers plans with additional benefits and coverage options. Medicare Part D (Prescription Drug Insurance): Introduce this part as an option to help with prescription drug costs. Medigap (Medicare Supplement Insurance): Explain that this insurance helps pay for costs that Medicare doesn't cover.

2. Tailoring Education to Individual Needs: Assess Needs: Help clients understand their specific healthcare needs & preferences to choose the right Medicare plan.

Consider Health Conditions: Discuss how chronic conditions & specific medical needs might influence their plan choices. Evaluate Costs: Help clients estimate their potential out-of-pocket expenses under different plans. Consider Provider Networks: Help clients understand if their preferred doctors & hospitals are included in any potential plans.

3. Enrollment & Timeline:

Initial Enrollment Period: Explain the 7-month window when new Medicare beneficiaries can enroll. Annual Enrollment Period: Highlight the opportunity to switch Medicare plans during the annual period. Other Enrollment Periods: Discuss special enrollment periods for certain circumstances.

Answer: The most important question about Medicare that you may not have considered is: "Are there gaps in my coverage that could lead to unexpected out-of-pocket costs?". Original Medicare (Parts A and B) leaves significant expenses uncovered, and while Medicare Advantage plans (Part C) offer more comprehensive coverage, they often come with their own limitations.

Here's why this question is crucial:

Original Medicare has limitations: Original Medicare only covers a portion of your healthcare expenses. It doesn't cover routine dental, vision, or hearing care, or long-term care. Even for covered services, you'll face copayments, coinsurance, and a deductible.

Medicare Advantage plans have their own gaps: While Medicare Advantage plans often offer better coverage, they might have network restrictions, require pre-authorization for some services, and have their own copayments and deductibles. You may also face penalties for using out-of-network providers.

Understanding your plan's limitations is key: Carefully review your plan's benefits document, formulary (if it's a Part D plan), and provider network to identify any potential coverage gaps or limitations.

Consider supplementary coverage: You may need to consider purchasing a Medigap policy (Medicare Supplement) to help fill gaps in Original Medicare or explore other coverage options like supplemental plans offered by your employer.

Be proactive in asking questions: Don't hesitate to contact your plan or Medicare's website to clarify any uncertainties about your coverage. Understanding your plan's limitations and potential costs is crucial for making informed decisions about your healthcare.

Answer: The "donut hole" in Medicare Part D, a period where you paid a higher percentage of your prescription drug costs, is being eliminated in 2025. Instead, there will be a new out-of-pocket spending cap of $2,000, and once you reach that limit, you won't pay anything for covered prescriptions for the rest of the year.

Here's a more detailed breakdown:

What was the "donut hole"?

It was the coverage gap in Medicare Part D, where you had to pay a higher percentage of your prescription costs after your plan had paid a certain amount towards your medication. This could lead to unpredictable and potentially high out-of-pocket expenses.

What's the new out-of-pocket cap?

In 2025, your annual out-of-pocket costs for covered prescription drugs will be capped at $2,000.

What happens after you reach the $2,000 cap?

Once you reach that limit, your costs for covered prescriptions will be $0 for the rest of the year. This means you won't have to pay any copayments or coinsurance for covered drugs.

How will this affect me?

This change should make your prescription drug costs more predictable and manageable, especially if you have chronic conditions and need ongoing medications.

What about other changes to Medicare in 2025?

Besides the elimination of the donut hole, there are also changes to Medicare Part A and Part B premiums and cost-sharing, and adjustments to income-related premium surcharges.

In essence, the elimination of the donut hole and the implementation of the out-of-pocket spending cap aim to simplify Medicare Part D coverage and make it more affordable for beneficiaries like you.

Answer: In general, Medicare Part B covers a variety of telehealth services, including virtual visits with doctors and other healthcare professionals, regardless of whether you live in a rural or urban area. Specifically, for beneficiaries in rural areas, telehealth is covered when accessed from a rural health clinic, critical access hospital, federally qualified health center, or certain other designated facilities. See what follows for a more detailed breakdown:

Coverage:

Medicare Part B covers telehealth services, which include virtual check-ins, virtual evaluations, and other virtual visits.

Location:

For telehealth services, you can be located at home or in a healthcare facility when receiving the service.

Rural Areas:

In rural areas, telehealth is covered if accessed from a qualifying location, such as a rural health clinic, critical access hospital, or federally qualified health center.

Geographic Restrictions:

While some telehealth services may have geographic restrictions, many are now covered regardless of location. For example, behavioral/mental health services can be delivered to patients in their homes, even in urban areas.

Out-of-Pocket Costs:

You will typically have to pay a Part B deductible and 20% coinsurance for telehealth services, as with other Medicare-covered services.

Medicare Advantage:

If you have a Medicare Advantage plan, you'll need to check with your specific plan provider for details on coverage and out-of-pocket costs.

Answer: In the catastrophic coverage phase of Medicare Part D, you pay $0 for covered prescription drugs for the rest of the year after you've reached the out-of-pocket maximum. This maximum is $2,000 in 2025. Once you've reached this limit, the plan covers 100% of the cost of your covered drugs.

Here's a more detailed breakdown:

Out-of-Pocket Maximum:

You reach this point after accumulating $2,000 in out-of-pocket costs for covered drugs.

No Additional Costs:

After hitting the maximum, you don't pay any copays, coinsurance, or deductibles for covered drugs for the rest of the calendar year.

Coverage Simplification:

This phase eliminates the coverage gap (also known as the "donut hole"), which used to exist before 2025.

Ongoing Premium:

You still need to pay your monthly Part D premium, but you won't have any further out-of-pocket costs for covered drugs.

Answer: There is no specific limit to the number of physical therapy sessions Medicare will cover or how much Medicare will pay toward physical therapy services. Medicare will cover all physical therapy that a healthcare professional considers medically necessary.

Answer: Yes, Medicare's costs are increasing and there are concerns about its long-term sustainability. The aging population and rising healthcare costs are driving up spending, while the Medicare Hospital Insurance (HI) Trust Fund is projected to be depleted in the future.

Elaboration:

Rising Costs:

Medicare spending is projected to increase significantly, rising from 3.1% of GDP in 2023 to 5.4% by 2054. This is due to factors like an increasing number of older adults eligible for Medicare and rising healthcare costs.

Population Aging:

The aging population is a major factor in the rise of Medicare costs. As more people reach retirement age, the number of beneficiaries in the program increases, leading to more claims and higher overall spending.

Projected Trust Fund Depletion:

The Medicare Hospital Insurance (HI) Trust Fund is projected to be depleted by 2026. This means that the program may need to rely on other sources of funding or face cuts in benefits to stay solvent.

Other Sustainability Issues:

Beyond the HI Trust Fund, Medicare faces other sustainability challenges, including rising spending in the Supplementary Medical Insurance (SMI) trust fund and concerns about rising premiums and cost-sharing for beneficiaries.

Need for Reform:

To address these challenges, various proposals for Medicare reform have been discussed, including adjustments to payment systems, enrollment options, and benefit packages.

Answer: When a spouse dies, the surviving spouse can receive benefits from both their own Social Security record and their deceased spouse's record, but not both at the same time. The surviving spouse will receive the higher of the two amounts.

Here's a more detailed explanation:

Survivor Benefits:

Upon a spouse's death, the surviving spouse may be eligible for "survivor benefits" on the deceased spouse's Social Security record. This benefit is a percentage of the deceased spouse's retirement benefit, typically between 71.5% and 100%.

Retirement Benefits:

The surviving spouse can also receive their own Social Security retirement benefits, which are based on their individual work history.

Choice:

Social Security will pay the surviving spouse the higher of their own retirement benefit or the survivor benefit on the deceased spouse's record. You cannot collect both.

Other Considerations:

There are other survivor benefits available for families, including a one-time death payment and potential benefits for children.

Answer: Seniors should be cautious about overhyped benefits in Medicare Advantage plans, particularly regarding "free" benefits like dental or vision coverage, as these often come with limitations or caps. They should also be wary of claims of lower premiums or no out-of-pocket costs, as copays & coinsurance can still apply. Here's a more detailed breakdown of what to watch out for:

1. "Free" or Limited Benefits:

Dental and Vision: Brochures & ads may tout "free" dental or vision coverage, but average coverage limits for vision are often minimal (e.g., $160), and dental coverage may have annual dollar limits (e.g., $1,000 or less).

Fitness:

Fitness benefits might have restrictions on usage times or gym access.

2. Copays and Out-of-Pocket Costs:

Despite $0 premiums:

Many plans have zero premiums, but beneficiaries still have to pay copays and coinsurance for services.

Annual maximums don't cover everything:

The annual maximum out-of-pocket costs for medical care often exclude prescription drug costs.

3. Network Restrictions and Prior Authorization:

Provider Networks:

Some plans restrict coverage to in-network providers, limiting choices for specialists or preferred doctors.

Prior Authorization:

Many plans require prior authorization for certain services, which can delay or even deny care.

4. High Premiums and Unexpected Costs:

Monthly Premiums:

While some plans may have low or zero premiums, beneficiaries still need to factor in the Medicare Part B premium, which is $185 in 2025, according to the National Council on Aging (NCOA).

Unexpected Costs:

Some beneficiaries may face unexpectedly high costs when they become ill or discover that their network lacks the necessary providers.

In short, seniors should carefully evaluate Medicare Advantage plans beyond the surface-level benefits and consider the potential drawbacks like network restrictions, prior authorization, and hidden costs.

Answer: A common Medicare myth, even among some agents, is that you can enroll in Medicare Part B at any time after age 65 without penalty. This is incorrect, as there are specific enrollment periods and penalties for late enrollment. Enrollment periods are designed to ensure people don't delay coverage unnecessarily. Delaying enrollment can result in a penalty.

Answer: Medicare Advantage plans can potentially save individuals money, particularly when compared to original Medicare with a Medigap policy. Many Advantage plans have no premiums or low deductibles, and they often offer a maximum out-of-pocket spending limit, which can protect beneficiaries from large healthcare bills. However, the actual savings depend on individual circumstances and the specific plan chosen.

Here's a more detailed look:

Premiums and Deductibles:

Many Advantage plans have lower premiums than original Medicare, with some even offering $0 premiums. Additionally, deductibles may be lower or nonexistent.

Maximum Out-of-Pocket Costs:

Medicare Advantage plans typically have a maximum out-of-pocket limit for covered services, which can be lower than the potential costs under original Medicare. Once this limit is reached, the plan covers 100% of the remaining covered services for the rest of the year.

Additional Benefits:

Advantage plans often include additional benefits not covered by original Medicare, such as vision, dental, and hearing care, which can lead to long-term savings.

Potential Savings on Specific Services:

Research suggests that switching to a Medicare Advantage plan may lead to cost savings on certain services like laboratory testing and medical equipment.

HMO Plans:

If you choose a HMO plan, you may see even greater savings on healthcare services provided by your network.

Out-of-Network Costs:

While Advantage plans may save money for in-network care, out-of-network costs can be higher and may not be covered.

Individual Circumstances:

The savings potential of Advantage plans vary based on individual health status, frequency of healthcare needs, and the specific plan selected.

Medigap:

Choosing a Medigap plan alongside original Medicare can provide similar cost protections and out-of-pocket limits as Medicare Advantage, but with the benefit of no network restrictions.

Answer: No, original Medicare (Parts A & B) typically does not cover routine eye exams for glasses or contact lenses. However, Medicare does cover certain vision care services, particularly if you have a specific eye condition like diabetes, glaucoma, or macular degeneration, or if you're at high risk for these conditions. Some Medicare Advantage plans (Part C) may offer additional vision benefits, including routine eye exams.

Elaboration:

Original Medicare (Part A & B) Coverage:

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Original Medicare, which includes Parts A and B, generally does not cover routine eye exams for the purpose of obtaining glasses or contact lenses. This means that if you need a routine eye exam to update your prescription, you will likely need to pay for it out-of-pocket.

Medicare Coverage for Certain Conditions:

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Medicare does cover vision care services related to the diagnosis and treatment of specific eye conditions or if you are at high risk for developing such conditions. For example, Medicare covers annual eye exams for people with diabetes to check for diabetic retinopathy, and it covers annual glaucoma screenings for people at high risk for glaucoma.

Medicare Advantage Plans:

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Medicare Advantage plans (Part C), which are offered by private insurance companies, may offer additional benefits beyond Original Medicare, including vision care. Some Medicare Advantage plans may cover routine eye exams and eyeglasses or contact lenses.

High-Risk Groups:

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If you are part of a high-risk group for certain eye conditions (e.g., family history of glaucoma, diabetes), Medicare may cover certain eye exams or screenings related to those conditions.

Costs:

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If you are not covered by Medicare for a routine eye exam, the cost can range from $170 to $200, on average.

In summary, while Medicare does not cover routine vision care, it does cover vision care for specific conditions and may offer additional coverage through Medicare Advantage plans.

Answer: Prior authorization for a knee replacement means your insurance plan requires your doctor to get pre-approval before the surgery. This is a common requirement for higher-cost procedures like knee replacement, often to ensure it's medically necessary and to manage costs.

Here's a breakdown of why this might be happening:

Cost-Control:

Insurance companies and government agencies (like Medicare) use prior authorization to manage costs and ensure that treatments are medically necessary and not unnecessarily expensive, says the Center for Medicare Advocacy.

Medical Necessity:

Prior authorization helps determine if the knee replacement is medically necessary given your condition and other treatment options.

Plan Specifics:

Your insurance plan may have specific rules regarding prior authorization for procedures like knee replacement, even if your plan appears to cover it, according to Verywell Health.

Medicare Advantage:

If you have a Medicare Advantage plan, prior authorization is more likely than with Original Medicare (Parts A and B), especially for higher-cost services like surgery, says Healthline.

Interpreting "Good" Coverage:

The term "good coverage" can be subjective. While your plan might cover knee replacement, it could still require prior authorization, which is a standard process for many plans,

Answer: If you've lost your Medicare card, you can get a replacement through several online and phone options. You can sign in to your MyMedicare.gov account and print a copy, or log into your my Social Security account to request a mailed replacement. You can also call 1-800-MEDICARE (633-4227) to request a replacement.

Here's a more detailed breakdown:

1. Online:

MyMedicare.gov:

Sign in to your account and print an official copy of your Medicare card. If you don't have an account, you can create one at MyMedicare.gov.

My Social Security Account:

Log in to your account and request a mailed replacement card. You can also update your address in your account to ensure the card is mailed to the correct location.

2. By Phone:

Call 1-800-MEDICARE (633-4227) to request a replacement card.

3. In Person (at a Social Security Office):

While walk-in appointments may be limited, you can check with your local Social Security office to see if they are still accepting walk-in requests for replacement cards.

Important Notes:

Keep your Medicare number safe:

This is your unique identifier in the Medicare system and can be found on your new card or in your MyMedicare.gov or My Social Security account.

Update your address:

Ensure your mailing address is current with Social Security or the Railroad Retirement Board (RRB) if you worked for the railroad.

Securely destroy the old card:

Once you receive your new card, securely destroy the old one.

Consider laminating or using packing tape:

To protect your new Medicare card from damage, you can laminate it or cover it with clear packing tape.

Answer: Yes, it's generally a good idea to meet with multiple Medicare brokers and agents when you're exploring your options. Brokers often represent multiple companies, while agents may only represent one, so comparing different perspectives can be beneficial. Consulting with multiple professionals can help you find the plan that best suits your individual needs and budget.

Here's why it's advisable to meet with more than one:

Broader perspective:

A broker, representing multiple companies, can offer a wider range of options compared to an agent who only sells plans from one specific company.

Informed decision-making:

Meeting with multiple brokers allows you to compare different plans, coverage options, and pricing, helping you make a more informed choice.

Potential for better deals:

Some brokers may be able to negotiate better rates or find more favorable plan options for you compared to others.

Understanding your options:

Comparing different plans and talking to multiple professionals can help you understand the nuances of Medicare coverage and identify the best fit for your individual needs.