Gus Karigan, Medicare Insurance Broker

Answer: Yes, Medicare does cover mammograms. You are allowed preventative screening once per calendar year.

Routine annual mammograms are fully covered under Part B, which makes it easy for beneficiaries to stay on top of breast cancer screening.

Answer: Don’t choose based on the premium—choose based on how you want to access care.

Medicare Advantage often looks attractive because of low or $0 premiums, but it typically comes with networks, referrals, and prior authorizations. Original Medicare with a supplement costs more monthly, but gives you maximum flexibility—no networks, fewer restrictions, and predictable out-of-pocket costs.

So the real question is:

Do you want freedom to see any doctor nationwide without referrals? → Lean Original Medicare + Medigap

Or are you comfortable with a managed network to save on monthly premiums? → Medicare Advantage

If someone makes the decision purely on premium, they often regret it when they actually need care.

Answer: The single most important piece of advice:

Don’t miss your initial enrollment window—timing matters more than anything.

When you first become eligible (typically around age 65), you get a 7-month Initial Enrollment Period—3 months before your birthday month, your birthday month, and 3 months after. If you miss this window:

• You could face lifetime late enrollment penalties (especially for Part B and Part D)

• You may have gaps in coverage

• You might be limited to enrolling only during certain times of the year

Just as important—during this window, you often have guaranteed issue rights for supplemental coverage (Medigap). Miss that, and you could be subject to underwriting later, meaning higher costs or even denial.

Answer: Medicare Part B is the portion of Medicare that covers outpatient and medically necessary services (as opposed to hospital stays, which are Part A).

Here’s what it generally covers:

🩺 Doctor & outpatient care

• Visits to doctors and specialists

• Outpatient hospital services (no overnight stay)

• Second opinions before surgery

🧪 Preventive services

• Annual wellness visits

• Screenings (e.g., mammograms, colonoscopies, diabetes checks)

• Vaccines (like flu, COVID-19, pneumonia)

🧰 Medical supplies & equipment

• Durable medical equipment (DME), such as:

• Wheelchairs, walkers

• Oxygen equipment

• Hospital beds

🧠 Mental health services

• Counseling and therapy

• Psychiatric evaluations

• Substance use disorder treatment

🚑 Ambulance services

• Emergency transportation when other transport would be unsafe

🏥 Some home health services

• Part-time skilled nursing care

• Physical or occupational therapy at home

💊 Limited prescription coverage

• Certain drugs given in a doctor’s office (like injections or infusions)

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What Part B does NOT typically cover

• Most prescription drugs you take at home (that’s Part D)

• Routine dental, vision, or hearing care

• Long-term custodial care (like nursing homes)

• Cosmetic procedures

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Costs (basic idea)

• Monthly premium (most people pay one)

• Annual deductible

• Typically 20% coinsurance for covered services

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If you want, I can break down how much Part B costs in 2026 or explain how it works with Medicare Advantage vs. Original Medicare.

Answer: Typically out of network doctors who don’t participate in a particular plan may very well charge you for your visit. Always call in advance to make sure.

Answer: Typically, when enrolled in a Medicare supplement, vision is not covered. If you are in a Medicare advantage plan otherwise known as part C vision is included.

Answer: Yes—if you are retiring next year, you should review and coordinate your coverage with Medicare so you avoid coverage gaps or penalties. What you need to do depends primarily on your age and whether you currently have employer health insurance.

1. If you will be turning 65 when you retire

You’ll need to enroll during your Initial Enrollment Period (IEP), which begins 3 months before the month you turn 65, includes your birthday month, and ends 3 months after. During that window you typically:

• Enroll in Medicare Part A

• Enroll in Medicare Part B

• Decide whether to add a Medicare Advantage plan or a Medicare Supplement Insurance with a Medicare Part D plan.

2. If you are already 65+ and covered by employer insurance

When you retire and lose that employer coverage, you qualify for a Special Enrollment Period. In that case you would:

• Sign up for Medicare Part B (if you delayed it)

• Choose your supplemental coverage option (Medigap or Medicare Advantage)

• Add a Part D drug plan if needed.

3. Timing matters

You generally want your Medicare coverage to start the same day your employer coverage ends so there’s no lapse in coverage.

4. Documentation

If you delayed Part B because of employer coverage, you’ll usually submit forms confirming that coverage when enrolling.

Answer: I’m very sorry for your loss. ❤️

The reason your Medicare premiums went up is likely due to IRMAA/ Income-Related Monthly Adjustment Amount. Medicare calculates IRMAA based on your modified adjusted gross income (MAGI) from two years ago. When you were married and filed jointly, your combined income may have kept you in a lower IRMAA bracket. After the death of a spouse, your filing status changes to single, which can push your income into a higher bracket, increasing your Part B and Part D premiums.

If your income has dropped significantly since your spouse passed away, you can request a life-changing event appeal with Social Security using Form SSA-44. This lets them recalculate your premiums based on your current income rather than the prior two-year tax return, which may lower or remove the IRMAA surcharge.

Another reason your premiums may have jumped is you lost your household discount. In Medicare, if you have a spouse or room mate, you can take advantage of a household discount.

Answer: Generic prescriptions under a Medicare Part D plan can suddenly cost more for several reasons, even if you’ve been on the same plan for a while. One common cause is formulary changes — Part D plans can update their drug lists each year, and a generic may have been moved to a higher-cost tier. Changes in pharmacy networks or preferred tiers can also increase costs if you use a non-preferred pharmacy.

Another factor is coverage stage changes. Part D has stages including deductible, initial coverage, coverage gap (“donut hole”), and catastrophic coverage. Your out-of-pocket cost can rise if you enter a different stage. Additionally, generic drug prices can fluctuate** due to manufacturer or supply changes, which plans may pass along to beneficiaries.

To lower costs, check your plan’s current formulary and tier placement, ask your pharmacy about therapeutically equivalent generics and compare prices at different network pharmacies.

Answer: If your Medicare Advantage plan denied coverage for a specialist, start by requesting an Explanation of Benefits (EOB)to understand the reason for the denial, such as coverage limits, prior authorization requirements, or out-of-network status.

You can then file an appeal with your plan, usually within 60 days of the denial. If the plan upholds its decision, you can request an external review through Medicare’s Independent Review Entity or contact 1‑800‑MEDICARE for guidance. In some cases, your doctor can help request an exception for out-of-network care by providing documentation of medical necessity.

Keep detailed records of all communications, denial letters, and supporting documents and act promptly to ensure timely review and continuity of care.

Answer: If you didn’t enroll in Medicare at 65 and are now retiring, you need to take action to avoid gaps in coverage and potential penalties.

First, you qualify for a Special Enrollment Period (SEP). This period typically lasts 8 months starting the month after your employer coverage ends. During the SEP, you can enroll in Part A(hospital) and/or Part B (medical) without paying the late enrollment penalty, as long as you had creditable employer coverage while working.

Next, consider whether you need Part D (prescription drug coverage) and/or a Medigap/Medicare Supplement plan to help with out-of-pocket costs. Enrollment in these can also occur during your SEP. Make sure to gather information about your employer coverage, retirement date, and any current insurance so you can provide proof that you had creditable coverage — this helps avoid penalties and ensures continuous protection.

Answer: If you cannot provide **creditable coverage**—prescription drug insurance that’s at least as good as Medicare’s standard Part D benefit—it can affect your **Medicare Part D** enrollment. Without creditable coverage, delaying Part D enrollment may trigger a **permanent late enrollment penalty**, calculated as 1% of the national base Part D premium for each full month without coverage, added to your monthly premium when you join.

You may also face higher out-of-pocket costs for prescriptions until you enroll in Part D. If you lose other creditable coverage, you have a **63-day Special Enrollment Period** to sign up without penalty. Missing that window is when the late enrollment penalty applies, so timely enrollment is key to avoiding extra costs.

Answer: IRMAA (Income-Related Monthly Adjustment Amount) is an extra charge added to your **Medicare Part B** and **Medicare Part D** premiums if your income exceeds certain limits. Medicare uses your modified adjusted gross income (MAGI) from **two years prior** to determine whether you owe more than the standard premium. The higher your income tier, the higher your monthly adjustment.

To see if IRMAA applies to you, review your most recent tax return and compare your MAGI to the current IRMAA income brackets for your filing status. If your income is above the threshold, Social Security will automatically notify you of the higher premium amount. If your income has decreased due to a qualifying life event — such as retirement, divorce, or the death of a spouse — you can request a reassessment through Social Security to potentially lower or remove the surcharge.

Answer: You have a seven month window to enroll in Medicare. Three months prior to your birth month, your birth month and three months after your birth month. This is called your Initial enrollment period where you are guaranteed issue.

Answer: With Original Medicare (Part B), many preventive services are covered at $0 cost to you if your provider accepts Medicare assignment and you meet eligibility guidelines. These include the one-time “Welcome to Medicare” visit, yearly Annual Wellness Visits, and screenings such as mammograms, colon cancer tests, cholesterol and diabetes screenings, depression screening, certain cancer screenings, bone density tests, and vaccines like flu, COVID-19, pneumonia, and hepatitis B (when risk criteria are met).

However, you may still have costs if your provider treats a new or existing medical issue during a preventive visit, orders additional non-preventive tests, or performs a procedure (for example, removing a polyp during a screening colonoscopy). In those cases, the Part B deductible and 20% coinsurance can apply. Routine dental, vision, hearing aids, and most full physical exams are not covered under Original Medicare, though some Medicare Advantage plans may offer limited additional benefits.

Answer: Guaranteed Issue (GI) for a (Medigap/Medicare Supplement) plan means an insurance company must sell you a policy, cannot deny you coverage, cannot charge you more because of health conditions, and cannot impose waiting periods for pre-existing conditions. Medigap works alongside **Original Medicare** to help cover out-of-pocket costs like deductibles and the 20% Part B coinsurance. The strongest GI protection occurs during your one-time, six-month Medigap Open Enrollment Period, which begins when you are age 65 or older and enrolled in Medicare Part B.

You may also qualify for Guaranteed Issue in certain special situations, such as losing employer coverage, your **Medicare Advantage** plan leaving Medicare or your service area, or exercising a 12-month “trial right” after first joining Medicare Advantage. In these cases, you typically have 63 days to apply for certain standardized Medigap plans without medical underwriting. Outside of these protected periods, insurers in most states can require health screening and may deny coverage or charge higher premiums.

Answer: Usually NO!! If you consider a Medicare Advantage plan with a dental policy built in, then perhaps a portion of the implants would be covered. A stand alone dental policy is a good idea, but even then, doesn't pick up the whole cost.

Answer: The real question here is: Do you have a supplement to cover what Medicare doesn't cover. Did you know that Parts A and B only cover 80% of your medical? You will need a supplement to pick up the other 20% as well as a Part D, prescription drug plan. If you have all of these in place it is very reasonable to expect that your bills can be manageable and in many cases.

Answer: To get coverage for an oral blood thinner, you generally must be enrolled in a standalone Medicare Part D plan or a Medicare Advantage plan with drug coverage. Plans have a formulary (list of covered drugs), and most Part D plans include common blood thinners on that list. People assume that "All" drugs are covered in Part D plans..... not true. Even when covered, you’ll usually pay something — like a copay or coinsurance, and maybe a deductible first, depending on your plan and the tier your drug is placed in. Generics tend to cost less than brand-name drugs.

Answer: You can keep your Original Medicare and Medigap plan, and it’ll still work in Florida.

But it’s worth checking Florida’s Medigap rates — you might save money or find a better deal.

You’ll definitely need to update your Part D prescription plan for your new ZIP code.

Answer: Medicare Advantage plans can have a $0 premium, but they’re not zero-cost. You’ll still pay your Part B premium and out-of-pocket costs as you go. The key is understanding when and how you’ll pay — rather than being swayed by the “free” label.

Answer: Medicare no longer has a hard “cap” on therapy visits, but there is an annual “therapy threshold” (around $2,330 for 2025 for combined physical therapy and speech-language pathology services).

If your therapy costs go beyond that, your provider must document that the services remain medically necessary for Medicare to continue coverage.

Answer: 💰 Deductible

The amount you pay first before your insurance begins to share costs.

Example: If your deductible is $200, you pay the first $200 of covered expenses yourself.

💳 Copay (Copayment)

A set dollar amount you pay each time you get a service, like seeing your doctor or filling a prescription.

Example: You might pay $20 for each doctor visit, regardless of the total bill.

⚖️ Coinsurance

This is a percentage of the cost you pay after meeting your deductible.

Example: If your plan has 20% coinsurance, and your doctor visit costs $100, you pay $20 and insurance pays $80.

✅ In short:

Deductible = what you pay up front before coverage kicks in.

Copay = a fixed fee you pay each time you use a service.

Coinsurance = your share of the bill (a percentage) after the deductible.

Answer: “One big advantage of Original Medicare that many people overlook is the freedom and predictability it gives you. You can see any doctor or specialist in the country who accepts Medicare — no networks, no referrals, and no prior approvals. Plus, if you add a Medigap plan, your out-of-pocket costs can be very predictable. It’s simple, consistent coverage that travels with you wherever you go.”

Answer: Many people appreciate the simplicity of Original Medicare because it’s accepted by most doctors and hospitals across the country—usually without restrictions.

By contrast, Medicare Advantage plans involve a few extra steps. First, they operate within a network, so it’s important to make sure your doctors and hospitals participate in your specific plan. Second, these plans often follow a “pay as you go” structure, meaning you may need to meet certain copays, coinsurance, or a deductible before the plan pays the remaining costs. Additionally, if you need to see a specialist, you’ll often need a referral or prior approval from your primary care doctor.

With Original Medicare, you have the freedom to see any doctor or specialist who accepts Medicare, without needing referrals or worrying about network restrictions.

These are just a few of the main differences to keep in mind when choosing between the two options.

Answer: Working with a local Medicare agent versus a remote/virtual agent both have their pros and cons. Here’s a breakdown of the benefits of working with a local Medicare agent near you, and how they compare to a remote one:

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✅ Benefits of Working with a Local Medicare Agent (In-Person)

1. Face-to-Face Communication

• Some people feel more comfortable discussing personal health and financial info in person.

• Easier to build trust when you can meet someone physically.

2. Local Knowledge

• Local agents often have a better understanding of:

• Doctors and hospitals in your area that are in-network.

• Local plans and carriers that are more commonly used or perform well.

• Community-specific issues (e.g., rural access, local pharmacy networks).

3. Help with Paperwork

• You can fill out forms together and have someone check everything right there.

• This reduces mistakes and speeds up the enrollment process.

4. Ongoing, Personalized Support

• Easier to build a long-term relationship with someone you can visit again.

• If issues come up (like billing, coverage confusion), you may be able to stop by their office.

5. Seminars and Community Events

• Local agents often hold free informational sessions or community events where you can ask questions and learn about your options in a low-pressure environment.

6. More Accountability

• Local businesses often rely on reputation and referrals, so they may be more motivated to provide great service and maintain your trust.

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🤝 When a Local Agent Might Be Especially Helpful:

• You have complex healthcare needs or prescriptions.

• You’re not very comfortable with technology or online forms.

• You prefer face-to-face interactions.

• You want to understand which local doctors, hospitals, and pharmacies are covered.

Answer: Many seniors don't know how to navigate the Medicare landscape. I love educating seniors so they can learn and take control of their health.

Answer: Medicare Advantage is a private insurance plan approved by Medicare. It bundles: Part A + Part B and often includes Part D (prescription drugs)

It may offer extra benefits like dental, vision, hearing

You typically must use in-network providers (like an HMO or PPO).

There will be an Out-of-pocket maximum along with lower premiums than Original Medicare in some cases and less flexibility in choosing doctors and hospitals.

Answer: You have a 7 month window to apply for Medicare. The three months before your 65th birthday, the month of your birthday and the three months following your birthday. This enrollment period allows you guaranteed issue of your Medicare supplement.

Answer: You have two options. If you have traditional Medicare, you can purchase stand alone dental and vision insurance. If you have Medicare Advantage, typically dental and vision are bundled in.

Answer: Medicare plans CAN DIFFER in other states. It's best to align yourself with an agent who is licensed in the particular state.

Answer: Parts A and B cover 80% coverage. You need to fill the gap with a medigap/supplement to pick up the 20% outstanding balance.

Answer: Traditional medicare does not cover the cost of hearing aids. You might want to consider a Medicare Advantage plan as it may offer hearing aid benefits..

Answer: Having an indemnity plan would make sense as many advantage plans have higher out of pocket costs and higher deductibles. An indemnity plan would help pick up those costs and is very affordable.

Answer: Simply put, it all depends on your health needs, budget and lifestyle. Part D is prescription drug coverage added onto original Medicare and a medigap plan. Medicare advantage bundles Part D, dental and vision into one plan, usually with lower premiums, but with network restrictions and possibly higher out of pocket costs.

Answer: In a nutshell, creditable coverage in insurance that's considered as good as or better than Medicare's standard benefits.

Answer: Tech will play a major role, not only with medicare but with healthcare in general. Access to care via telehealth, digital records and edarly intervention using tools like remote monitoring and AI diagnostics will play a huge role.

Answer: There are Medicare Savings Programs(MSA'S) which can assist with Part A and B. You can also look for extra help/Low income subsidy to help with Part D. You can also check to see if your state offers additional programs or Medicaid to help cover costs.

Answer: You can change your medigap at any time, but in most states, you will have to go through medical underwriting unless you're in your guaranteed issue period.

Answer: Medicare Part D, also known as a prescription drug plan helps cover costs of prescription drugs reducing what you'll pay out of pocket. This will protect you in some cases from high costs and introduce you to a wide range of approved medications.

Answer: No, you didn't necessarily make a mistake! Medigap offers broad coverage and few network restrictions. If the pricing of medigap is becoming too much, you can always look at a Medicare Advantage plan to help balance costs. You'll still be able to travel, but may have the find doctors in your network ahead of time.

Answer: A licensed Medicare agent can help you compare different pricing and plans as well as helping understand how the A, B,C and D's of Medicare works and tailoring it to the clients specific health and financial needs.

Answer: Medicare will cover you if traveling to one of the US territories, but check with your plans coverage to make sure. Travel insurance is also a good idea to cover expenses as well.