Gregg Matheny

What's one piece of advice you wish every senior knew before picking a Medicare plan?

Answer: One thing that I wish every senior knew before picking a Medicare plan is the basic differences between a Medicare supplement and a Medicare advantage. I also wish that every senior understood the ramifications of selecting a Medicare advantage plan when you were first eligible for Medicare and how difficult the underwriting process can be to get on a Medicare Supplement plan when you are subject to underwriting.

Can you describe a time when you helped a client navigate a complex Medicare issue?

Answer: Every time a client calls me that is approaching their 65th birthday I help layout steps for what they need to do next depending upon where they are at for example, income levels, currently on SS, trying to continue work coverage. Etc.. since there are many routes to Medicare I tend to put on my “detective hat” and ask pertinent questions so that I can best educate my clients and give them the best Medicare plan that’s suited to their needs. I will ask about their gross monthly income to determine if they are eligible for any state benefits. If they are, I can guide them to where they would apply for such benefits and explain how it works with their chosen plan. I’m under the impression that this is always a two-way street, And That my clients healthcare needs may change. Because of this, I like to view myself as an employee, and my clients are the “boss”. I love solving problems, And helping people.

How do discount cards and resources affect my Medicare Prescription Drug plan?

Answer: Good question! Here’s a simple answer. It’s one or the other. If you pay for a prescription using your Medicare Prescription drug plan card Then you work towards Medicare‘s catastrophic coverage (in 2025 that amount is $2K), Meaning that whatever you spend towards covered medication’s, gets you closer to hitting your $2000 out-of-pocket maximum a.k.a. catastrophic coverage. once you hit $2000 out-of-pocket you no longer pay a penny for any covered medication’s. Using your Medicare prescription drug coverage will typically give you a pretty big discount on your medication‘s as it is a pre-negotiated discounted rate between the drug company and the insurance company.

If you were to use something like goodRX, you may get a discounted medication but there is no cap to what you may pay throughout the year. Everyone’s situation is different, so for some folks, I’m a huge fan of good RX but for others I strongly encourage sticking to using your Medicare prescription drug plan.

What is one of the the most common misconceptions people have about Medicare?

Answer: The most common misconception about Medicare is that you have to drop all of your previous coverage and get onto Medicare right when you turn 65. That’s not always true. If you have work coverage (employer sponsored plan), that is not going to cancel when you turn 65 Then you can do something called “delay part B”. What this does is it makes it so that you don’t have to pay a Medicare part B premium every month towards Medicare, you can continue with your work coverage, and when you decide to drop your work/employer coverage, you can get Medicare part B without incurring a penalty.

What’s the likelihood of Medicare covering gene therapy as it becomes more common?

Answer: The likelihood that Medicare will cover something like gene therapy In my opinion is getting increasingly better. I’ve been in this field for about eight years and I’ve seen A lot of growth and adaptation from Medicare. I think in the near future Holistic medicine, naturopathy, gene therapy, Stem cell Based procedures will all have some kind of benefit that will be covered by Medicare.

If you had to pick just one, what’s the worst Medicare-related decision someone can make?

Answer: I think one of the worst decisions that can be made when it comes to Medicare It’s to just decide not to be covered at all. Not being covered by an employer plan, And not having Medicare part B Does prevent you from having to pay a Medicare part B premium every month. However, If in the future, you ever decide that you need some kind of Medicare plan then at that point there will be a fairly large penalty associated with part B as well as part D. I’m not a fan of paying a monthly cost for something I don’t need, But I do usually see this decision come back and really hurt people. My role as a broker is really only to educate/enroll and I can’t force anybody to make a good choice or a bad choice.

Can I change my Supplemental/Medigap plan at any time?

Answer: Medicare Supplement plans can be changed anytime, however, they may be subject to underwriting depending upon the time period that you’re trying to enroll.

What’s one hidden Medicare expense that people don’t think about until it’s too late?

Answer: The biggest expenses that often creep up on folks are hospital cost and prescription drug deductibles on a Medicare advantage plan. On a Medicare supplement plan the annual rate increase can often sneak up and surprise folks. No matter what plan you’re on if your income is on the high side an IRMAA part B and part D can be A huge shock.

Will I be penalized if I do not enroll in Medicare when I turn 65?

Answer: Yes. Unless you have what Medicare considers “credible coverage” (coverage at the providers office and coverage at the pharmacy) from an employer plan. If you turn 65 and have employer coverage, you will still get Medicare part A (in most cases for free) But will not have to pay for Medicare part B And your Employer coverage will be primary.

What is the biggest mistake seniors make when enrolling in Medicare?

Answer: Not exploring their options enough And enrolling into the lowest premium plan is a mistake that seniors often make when enrolling into Medicare. It’s never a bad idea to educate yourself on your options. Sometimes it’s easy to take the “ Out of sight out of mind” Approach, but that usually ends in a penalty from Medicare.

What do you enjoy most about working with Medicare clients?

Answer: I enjoy helping clients plan for the future. I really enjoy hearing their background and their upcoming needs and helping them find a plan and a cost that works for them. I have been very fortunate in that most of my clients end up becoming my friends. I enjoy the process of building trust and being an expert in my field so that all of my clients can count on me year over year.

Do Medicare Advantage plans really save seniors money in the long run? Why or why not?

Answer: Yes and no. It really depends on the client. I do have clients that have been on a low-cost advantage plan for years and truly have not seen any specialist and take very little generic medication’s. Those folks have saved thousands of dollars over the years. I also have clients that were attracted to a low monthly premium, but have paid a lot in out-of-pocket cost for providers, hospital, states, specialist visits, MRI, etc.. The biggest disadvantage that I have come across on advantage plans is the limited network. I always encourage clients to pay close attention to an advantage plans “MOOP”. I will often compare that cost to a yearly predicted cost on a Medicare supplement plan to help paint a picture of the difference between advantage and supplement.

Why do some clients ignore your advice and end up in bad Medicare plans—what makes them resistant?

Answer: It does happen where clients will ignore my advice and end up on a bad plan. That is usually due to a plan having a few very attractive features like a high dental/vision benefit that the clients feel overshadows procedures/services that have higher than average costs or substandard RX coverage with high deductibles. I sure don’t steer clients to specific plans but rather teach them about their plan choices and highlight pros and cons.

What happens if I am already retired and collecting Social Security when I turn 65?

Answer: Easiest situation possible! Three months prior to your 65th birth month Social Security will start the process of getting you set to start on Medicare parts A and B on the first day of your 65th birth month. You don’t have to do anything besides keep an eye out on the mailbox for your Medicare ID card and instructions on how to pay your Medicare part B premium.

I’m retiring next year—do I need to do anything with my Medicare?

Answer: Yes, if you are currently over the age of 65 and you are on some type of employer coverage Then at least a month prior to your employer coverage canceling you’ll need to Get a hold of Social Security (I like SSA.Gov) and apply for Medicare part B only. You will subsequently get a few letters from Social Security stating that they need information about your previous employer plan before they start Part B. You may even need paperwork signed from your work so it’s best to give SSA plenty of time to start Part B.

What’s the best way for seniors to protect themselves from Medicare-related scams?

Answer: I am very biased!!, if my clients receive a letter or a phone call that seems sketchy at all I strongly encourage them to call me, text me, or take a picture of the letter that they received and send it to me. If seniors don’t want to reach out to an agent, Then they should keep in mind that they can always contact Medicare or Social Security to verify any request for info.

What if I missed my window to sign up?

Answer: Medicare does run a pretty tight ship And it does happen where occasionally someone will miss their election window. There could potentially be a late enrollment penalty If you have gone 63 days or more without credible coverage when you are eligible. It’s the job of Agent/brokers To know the Medicare election periods very well. To avoid that penalty from becoming even bigger, you’ll need to enroll in something in your very next election period.

Is Original Medicare or Medicare Advantage better? Why do you recommend one over the other?

Answer: Medicare advantage is great for covering a large number of services at a pre-negotiated lowered rate BUT You do have to stay with a carrier’s network And some procedures may require prior authorization Which can be very cumbersome at times. Original Medicare leaves you open to paying the full 20% that is not covered But you do not have a network of doctors that you need to stay within, rather any hospital or doctor that accepts Medicare would be someplace that you can go.

What is the biggest disadvantage of Medicare Advantage?

Answer: In my opinion, the biggest disadvantage with Medicare advantage Is that your Cost could be anywhere from $0 dollars Up to a plan maximum amount of pocket (In some cases $10,000) throughout the year. Medicare advantage is definitely attractive because of the low monthly premium, but it has potential to be more expensive than a supplement plan. Also, The fact that some procedures require prior authorization from the insurance company can be a real sore spot too.

Does Medicare cover eye exams, or are seniors left paying too much?

Answer: Original Medicare does not cover eye exams. Depending upon the plan that you have, you may have a low or zero dollar cost for a yearly eye exam. Cataract surgery with a standard lens is a zero dollar cost And is covered by Medicare.

How do Medicare Advantage star ratings affect the quality of care I can expect?

Answer: Medicare advantage ratings are a great way to rate the effectiveness of a plan. If you just go off of a plans benefit amounts, you may be turning a blind eye to poor service or low network quality. The star ratings really do give an accurate description of how well or poor a plan performs..

Why do some seniors end up paying lifelong penalties for Medicare Part B or Part D?

Answer: When they were originally eligible for Medicare part B or a part D plan they did not enroll and Medicare starts keeping track after 63 days or more In which you were uncovered. The kicker is that Medicare doesn’t assess that penalty until you get Medicare part B. Same goes with part D, If you didn’t get a prescription plan when you were first eligible for one and 63 days or more has passed then Medicare will keep track of the number of months that you didn’t have a prescription drug plan and a penalty that roughly ends up being about $.35 per month (in AZ) gets multiplied by the number of months that you didn’t have prescription drug coverage. That amount gets added to what your part D premium is.

What’s the biggest frustration Medicare agents have when helping clients enroll?

Answer: Insurance companies don’t fill in Medicare brokers on changes that a client may make. The biggest frustration ends up being a lack of communication, Because when the client calls up and says that they’re frustrated with Something, they have to fill in the Medicare broker on what’s going on. This can be alleviated with simple open communication.

What role do annuities play in retirement planning?

Answer: I don’t write any annuities, but I know enough to know that they can play a major role at times. Like most insurance policies Annuities have certain situations or clients that they would fit better than others

Are Medicare plans and requirements different for every state?

Answer: Medicare advantage plans can actually vary from county to county. Medicare Supplement plans are standardized across every single state But will typically have a different monthly premium, depending upon the ZIP Code that you are enrolled in or currently live in.

I have Medicare Advantage with a PPO, and I’m curious if my annual wellness visit is free or if I’ll owe something for it.

Answer: Your plan more than likely will have a zero dollar co-pay for your annual wellness visit however, it’s always a good idea to double check your summary of benefits to make sure.

What’s one Medicare decision that too many people regret later?

Answer: Trying to save money upfront by going with an advantage plan rather than taking time to do research. Another big regret that I have come across is the decision to opt out of an RX plan, which can be costly down the road. Medicare keeps track of the number of months that you don’t have RX coverage, and then down the road when you do get coverage Medicare will multiply that number of months by the average base premium of your states RX plans, that number then get multiplied by .01 and then you have the monthly amount that will be added on to your RX coverage for life.

What additional coverage options are available for international travelers?

Answer: For international travelers I strongly recommend looking in to some measure of travelers insurance. While most plans will cover an ER visit worldwide, it may be wise to have a travelers insurance plan specific to your scenario.

I’ve been on a Part D plan for a while, and I’m wondering why my generic prescriptions suddenly cost more. Did something change?

Answer: Yes, unfortunately carriers can occasionally alter the tier of a medication from “generic” (tier1) to “preferred generic” (tier2). In some cases a generic medication may even jump up to a tier 3! I have noticed that these changes usually happen when the plan starts anew on 1/1. Most carriers have an online RX lookup tool for members, you may try looking up your medications every so often.

What are some lesser-known benefits or services that my Medicare plan might cover that I could be missing out on?

Answer: Most plan benefits are very visible, but the ones that I find are most often under utilized are the fitness benefits related to wearable devices. In some cases there is also an amount that can be reimbursed for the purchase of gym equipment. Also, most plans incentivize healthy habits. You may call the member services number on the back of your card and ask if there is a reward for getting a flu shot or reporting daily number of steps.

I picked a Medicare Advantage plan last year, and I’m not sure if my hearing aids are covered. How do I figure this out?

Answer: The best way I have found to find if a service or product is covered is by calling the insurance carrier directly. A lot of the “is this covered?” Questions come after a service or product has been purchased which makes things a little more difficult. Ask the carrier ahead of time if a certain hearing aid, dental procedure, durable medical equipment, etc.. is covered and at what in network facility?

What do I need to do if I didn’t take Medicare at 65 and am now retiring?

Answer: Hopefully you chose not to get Medicare because you had an employer plan. If that is the case, reach out to SSA (I like SSA.GOV) and apply for Medicare part B. SSA will reach out to you with a few forms that they want your employer to fill out as well as some info about your past plan. If that’s not the case and you are just now getting onto Medicare and you haven’t had other credible coverage then there will be penalties added onto your Medicare part B premium as well as a penalty added on to your part D premium (LEP). Depending upon how much time has passed will determine how big or small your penalty is.

Does Medicare cover health care services on a cruise ship?

Answer: Good question! Yes and no. More than likely your cruise ship will not accept your Medicare plan card, or your original Medicare ID card. You will have to pay up front and then submit the bill to your plan for reimbursement once you are home. This will more than likely fall under an “urgently needed services” category.

Why is the new $2,000 out-of-pocket maximum for drug costs important?

Answer: The $2000 MOOP is important for a few reasons.

1. You can predict a yearly cost even if you take several expensive meds.

2. While it is nice that the maximum out-of-pocket is only 2000, keep in mind that most plans now have a fairly large prescription drug deductible for brand-name medication‘s.

3. All carriers by law have to offer. What’s called an M3P program. They take your current medication’s and predict yearly cost and divide that number by 12 and that then becomes your part D premium every month. This will be coming in handy if you don’t want to pay per medication.

What should I do with my Medicare plan if I’m diagnosed with a rare disease requiring specialists?

Answer: Great question.if that rare disease is going to lead to expensive complications down the road, it may be a good idea to look into a supplement plan like a “G” or “N”. The tough part would be passing underwriting since you’ve recently been diagnosed. If you’re unable to pass underwriting Then you may just try to get familiar with your advantage plan costs and if possible, get familiar with all of your lesser expensive “in-network” options. It may be a good idea to utilize your broker or contact the Member Services number for your insurance and get a list of providers in your area.

Do I have to answer health questions when switching from one Supplemental/Medigap plan to another?

Answer: Yes, each carrier has a set of underwriting questions, and some even have a list of medication’s that if you take for any number of given diagnoses, you may be disqualified for enrollment into that supplement plan. Some are easier to get onto than others. If you narrowly don’t pass underwriting for a certain carrier, it may be a good idea to try another carrier.

For Medicare Part D, why would someone pick a plan with a high total cost?

Answer: I don’t know. My thought is that you should look at how much the premium is for that part D plan, and compare that with the predicted yearly total cost for all your meds. If the lower premium plans have a high medication cost it may not be worth it for the upfront savings. Most brokers, including myself, have a tool in which we will plug in your medications And see what those would cost on each individual part D plan. I like to look at all of my costs to see the big picture.

How will the new 2025 Medicare Part D out-of-pocket cap impact seniors and prescription drug costs?

Answer: I think they will impact seniors in a good way for the most part. Prior to the new out-of-pocket cap most of my clients were paying well over $2000 per year in medication cost. For them that new cap is a great thing. Most plans also introduced a deductible to tier 3, tier 4, and tier 5 medication’s, so to those that take one tier 3 medication I think they’ll end up spending more than they did last year. For those that take lots of medications I think this is a great thing.

Am I eligible for a Special Enrollment Period if I lose employer coverage?

Answer: Yes that’s a great example of a “special election period”. Most brokers will refer to this as an LEC. Although Medicare does give you a few months to get onto a new plan, I think it’s best to not go “uncovered” for any period of time. If you coordinate with the broker, they can usually make this process very seamless.

Does Medicare fully cover nursing home care, and are there alternatives?

Answer: No it does not. Yes Medicare does help out with care from a skilled nursing facility. Days 1-20 Are covered in full by Medicare. Days 21 through 100 there will be a set co-pay of a little over $200 per day. After day, 100 you are responsible for all costs. Unfortunately Medicare doesn’t cover any type of custodial care or long-term care.

How does life insurance contribute to financial planning?

Answer: Life insurance can be very crucial to financial planning. Life insurance is something that should be in investigated sooner rather than later. A good benefit Rich policy May offset Some costs in the case of a passing that incurred medical debt.

I’ve got a Medicare Advantage plan, and I’m curious if my upcoming eye surgery is fully covered or if I’ll owe extra out of pocket.

Answer: That would be a great question to ask the provider prior to the surgery. A good ophthalmologist office Is usually very aware of the codes that they will bill to Your Medicare advantage plan And they may Tell you your cost. You should also be able to contact your Medicare advantage plans member services number and they can answer that question for you. If it is a cataract surgery, that’s a little different. Medicare fully covers cataract surgery with a standard lens. If you are using any type of upgraded lens, then Medicare will not pay for the upgraded lens And you will be financially responsible for that cost.

What’s an underrated benefit of Original Medicare that many people overlook?

Answer: The ability to go anywhere that Medicare is accepted is a huge benefit of original Medicare. Another underrated benefit is that if you have worked for more than 40 Quarters then Medicare part A is premium free.

What role do you think technology will play in the future of Medicare?

Answer: I’ve been in this long enough that when I started out, I was filling out applications on paper and faxing them into carriers. I’ve seen the rise of technology in the Medicare world, and it sure does possess a learning curve. Once you’ve got that learning curve down, technology becomes crucial to everything but the benefit is that things happen so much faster now.

Brokers can see formularies and provider directories with the click of a few buttons,

Beneficiaries can get answers really Fast, Claims can be seen almost instantaneously, and premiums get paid with never having to write a check. Technology has made things easier in the Medicare realm. I think overtime technology is going to be more and more crucial To the daily workings of Medicare .

What does Medicare Part B cover? Is it enough?

Answer: Medicare part B covers quite a bit, including: Doctors, exams, outpatient care, preventative care, durable medical equipment, therapy, home health services, ambulance. Keep in mind that the Medicare part be deductible for 2025 is $257. If you’re on a Medicare supplement plan, you would have to meet that deductible For any of the above listed services.

If I need long-term care in the future, how does Medicare fit into that plan, and what should I be doing now to prepare?

Answer: Medicare unfortunately does not cover long term care. However skilled nursing facilities, some home health care, and hospice are covered. If you’re looking for long term care coverage your best bet would to be looking into life insurance policies with a “long term care rider”, your premium would change depending upon the length of the benefit I.e. a 3. yr benefit period would be less than a 10 yr or lifetime period. I would strongly encourage doing this now. If you try to wait till you need it you will probably get denied.

I have Original Medicare, and I’m wondering if I’d save more on my dental cleanings if I switched to a Medicare Advantage plan instead.

Answer: You definitely would save more on an advantage plan in the dental category. Everybody’s needs vary and so it really depends on what is best for you but if you’re medical needs are very easily managed or non-existent then it’s not a bad idea to invest more into your vision, dental, and hearing (which original Medicare doesn’t cover) and Medicare advantage has a reputation for offering some high dental benefits. The first step is to talk to a broker about “good plans” with a good dental benefit.

If a senior is turning 65 but still working, should they enroll in Medicare or delay it?

Answer: Delay it. If your employer coverage is working for you and your needs, as well as not costing you an arm and a leg then go ahead and “delay part B”. Medicare will have a known cost of at least $185 per month (part B premium) + whatever plan you add on top of that. If you’re currently paying more than that and not “using your employer plan benefits” then you may be better off getting onto Medicare. A broker can help you make a “pros and cons” list and think through your options.

How can I lower my Medicare Part B premium if my income drops after retirement?

Answer: All states have a threshold for “state Assistance” that if you are under then it will pay for your Medicare part B as well as some deductibles and some RX costs. If you don’t meet the financial criteria then your only other option to lower the part B cost is with a benefit called a “part B reduction”. Be careful when looking at plans that offer this because a few of them are “MA ONLY” plans which means they don’t include RX coverage. If you will be relying on your plan to get medications, then you want an MAPD with a part B premium reduction.

I've heard about IRMAA affecting my Medicare premiums. How can I find out if it applies to me, and how does it work?

Answer: IRMAA is a way for Medicare to charge those in higher income brackets more for their part B and part D premiums. IRMAA always goes off of your income from 2 years prior, so if you sold a house for $1 million in 2023, Then in 2025 you will pay the highest part B and part D premiums. You’ll need to search “Medicare IRMAA 2025” to find the most up to date charts and plan accordingly. Keep in mind that you will pay a part B as well as a part D premium.

How can you create a comfortable environment for discussing Medicare with your parents?

Answer: If you come from a place of love and concern for your parents then you’re starting off correctly. Another very important part is to have a broker with you that can speak very clearly and explain answers very simply. Medicare can be difficult, so presenting an environment in which Medicare can be simplified and questions can get answered is a good scenario.

How can I select the right healthcare company and representative to work with?

Answer: A good representative Will usually be very easy to spot ( Medicare agents hub ). If you End up finding someone that you trust then the carrier that you go with becomes Not as important. I have several clients and I can speak from experience in saying that putting them all on the same“good” plan Is not the right thing to do. Every individual is different, And a good representative should match up your needs with a plan that’s best for you.

I got a call from a “Medicare agent” promising me free groceries and I almost fell for it. Why is this kind of marketing allowed?

Answer: It’s unfortunate but there are a few loopholes in Medicare marketing guidelines that allow agents to discuss benefits associated with “DSNP’s” (Dual Special needs plans) on cold calls. These types of plans require that you have both Medicare and Medicaid, if you have both of these then there may be a DSNP plan available in your area that includes a”healthy food and produce” benefit that gives you a monthly allowance towards OTC items and groceries. Unfortunately I think a commonly used tactic is the “bait and switch”. Agents/brokers have to be a little more transparent if you were to physically meet them and go over your plan options. Be a good practice To ask these individuals “how are these benefits available to me” or simply just hang up. This sure isn’t a way to conduct good business but some brokers do engage in this.

I picked a Medicare Advantage plan because of the dental and now I found out it only covers cleanings. Why didn’t anyone tell me this upfront?

Answer: You should have been told. If you worked with a broker, you may call them up and let them know you’re unhappy and feel shorted. Advantage plans do change benefits a year as well. I would treat this as a learning curve and in the future whenever you look at an advantage plan Be sure to ask specifics When it comes to dental.

Gregg Matheny, Medicare Insurance Agent

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