James Hale, Medicare Insurance Broker

Answer: You do not have to pay anything at all to work with a local, Medicare-licensed insurance agent.

Here’s why it’s free:

Medicare rules do not allow licensed agents to charge you a fee for helping with Medicare Advantage, Medigap, or Part D plans. The insurance companies pay the agent directly (through commissions set by Medicare). Your monthly premium and the benefits you receive stay exactly the same whether you enroll directly with the insurance company or through an agent.

Using a good local agent is often the smartest and easiest way to compare plans and enroll. They can explain your options in plain English, answer your questions, and help you choose the plan that fits your needs, all at no cost to you.

Answer: Top Reasons-

Too much paperwork and denials: Medicare Advantage plans often require “prior approval” for cancer treatments. This creates extra work, delays, and more denials than Original Medicare.

Lower and slower payments: These plans usually pay hospitals less than traditional Medicare for the same care. Cancer treatment is expensive, so some centers lose money. Insurers may also take longer to pay.

Limited networks: Medicare Advantage uses smaller networks, and many top cancer centers are excluded.

How This Affects You-

Original Medicare gives you access to almost any hospital or doctor that accepts Medicare, with much less paperwork. However, it has no yearly out-of-pocket limit.

What You Would Typically Pay-

Part A (hospital/surgery): Deductible per benefit period + daily coinsurance for long stays.

Part B (outpatient chemo, radiation, doctor visits): After the deductible, 20% coinsurance with no maximum.

Prescription drugs: Covered under Part D with its own deductible, copays, and out-of-pocket maximum.

Example: $100,000 in outpatient care could cost you $20,000 or more out-of-pocket. Immunotherapy and targeted drugs will cost even more.

How Most People Protect Themselves-

A Medigap policy usually covers the 20% coinsurance and deductibles, often bringing costs close to zero. You can buy any Medigap plan guaranteed issue (no health questions or denials) during the first 6 months after enrolling in Part B.

Bottom line: Traditional Medicare gives you broad access to doctors and hospitals with little prior authorization hassle, which is great for cancer care. But without a Medigap plan, a serious diagnosis can create large and unpredictable bills because there is no maximum on your liability.

Answer: Neither manufacturer's copay cards nor the Breztri Zero Pay program is available for Medicare patients. Federal rules prohibit them for anyone with government-funded insurance (Medicare Part D, Medicare Advantage, Medicaid, etc.). They are limited to commercial/private insurance only.

Main Option: AZ&Me Prescription Savings Program (AstraZeneca)

This patient assistance program provides free or low-cost Breztri for eligible Medicare patients, with the medication shipped directly to you.

Eligibility (key points):

*U.S. resident

*Prescribed Breztri by a U.S. licensed provider

*Household income generally ≤ 300% of the Federal Poverty Level

*A Medicare enrollee who still can’t afford the drug after plan coverage

*Usually not eligible if enrolled in Medicare Extra Help (LIS)

*No other duplicative assistance

Eligibility is reviewed on a case-by-case. Your doctor must provide a prescription.

Other Ways Medicare Patients Can Save:

Medicare Extra Help (LIS) can lower or eliminate Part D copays (apply at SSA.gov or Medicare.gov).

State Pharmaceutical Assistance Programs, check via Medicare.gov or your state.

Nonprofit assistance, groups like the Patient Advocate Foundation, may help.

Switch plans, compare Part D or Medicare Advantage plans during open enrollment for better Breztri coverage.

Pharmacy discount cards, SingleCare or GoodRx (cash price only, not with insurance).

For the latest details, contact us.

Answer: Breztri Aerosphere, a brand-name COPD inhaler, is covered by most Medicare Part D and Medicare Advantage plans with prescription drug coverage included. Your actual cost depends heavily on your specific plan.

What Affects Your Cost?

Your plan’s formulary tier — Lower tiers often mean a flat copay (~$45–$50). Higher tiers can mean coinsurance (25–40% of the drug’s cost). Generally speaking, the lower the tier the lower the cost.

Deductible — Many Part D plans have one that you pay fully before coverage kicks in for brand name drugs.

Coverage phase — Once you reach the annual out-of-pocket cap on covered Part D drugs, you pay $0 for the rest of the year.

Prior authorization or step therapy — Some plans require prior authorization or step therapy (trying cheaper inhalers first).

Pharmacy and plan type — Costs can vary between standalone Part D and Medicare Advantage plans.

Answer: Yes, zero-premium Medicare Advantage plans are real. Medicare pays private insurers a fixed amount per enrollee (currently in the neighborhood of $12,000 per year in 2026). Insurers can use these payments to cover benefits without charging you an extra premium and still make a profit. Many also bundle in Part D prescription drugs, dental, vision, hearing, fitness, and/or transportation. You still pay the Medicare Part B premium, some plans offer a "Part B giveback" that reduces or offsets this, but not all plans do.

The Catches-

Out-of-pocket costs: Zero premium doesn’t mean zero costs. You’ll still face deductibles, copays, and coinsurance for doctor visits, hospital stays, and drugs. Plans cap your annual out-of-pocket maximum, after which they cover 100%.

Network restrictions: Most zero-premium plans are HMOs that require in-network providers and sometimes specialist referrals. Out-of-network care is usually not covered, except emergencies. PPOs may give more flexibility but cost more when used outside the network.

Higher costs for heavy users: Healthy people often save money. Those with chronic conditions, frequent hospitalizations, or expensive drugs may pay more overall than someone with Original Medicare and a good Medigap policy.

Annual changes: Benefits, networks, drug lists, and extras can change every year during open enrollment. Dental, vision, hearing, and other perks have annual caps and can be reduced or eliminated.

Answer: Yes, moving to a new state can give you a rare second chance if you’re on a Medicare Advantage plan. If you have a Medicare Advantage plan and you move out of its service area, you do indeed get Guaranteed Issue rights. You can drop your Advantage plan and buy certain Medigap plans without medical underwriting, this means no health questions and no denials, even with pre-existing conditions.

This Special Enrollment Period usually lasts up to 2 full months after your move (and can start the month before if you notify early).

Answer: Here’s exactly how your Medicare coverage changes — and one unique opportunity many people miss:

*Original Medicare (Parts A & B)

No change — It follows you anywhere in the U.S.

You can see any doctor or hospital that accepts Medicare nationwide.

Your Medicare card stays the same.

*Medigap (Supplement)

Your current policy moves with you nationwide.

Just notify your insurance company of the new address.

Premiums may go up or down based on the new state/zip code.

*Medicare Advantage (Part C) or Part D Drug Plan

These are local plans — most won’t work in your new state.

You’ll need to switch during your Special Enrollment Period (see below)

If you notify your current plan before you move: Your SEP starts the month before your move month and continues for 2 full months after you move.

If you notify your plan after you move: Your SEP starts the month you notify them and runs for 2 full months after that.

🚨 This is a BIG Opportunity If You’re on Medicare Advantage

If you have a Medicare Advantage plan and you’re moving out of its service area, this move gives you Guaranteed Issue (GI) rights for Medigap.

That means you can drop your Advantage plan and buy a Medigap policy WITHOUT medical underwriting — that means no health questions and no denials, even if you have pre-existing conditions.

This is one of the rare second chances to switch to Medigap penalty-free. Many people use a planned move exactly for this reason.

Answer: Zero-premium sounds like ‘free Medicare’ — but it’s not zero-cost. It’s more like a cell phone plan with $0 monthly fee… until you start using data, minutes, or roaming.

The honest breakdown:

✅ Zero premium = You pay $0 extra to the insurance company each month for the Medicare Advantage plan.

❌ You still pay your regular Medicare Part B premium — about $202.90 per month in 2026 for most people.

❌ When you actually use healthcare, you pay copays, coinsurance, and deductibles:

Doctor visits: often $20–$50 each

Hospital stays: hundreds or thousands before the plan kicks in fully

Prescriptions: copays that add up fast

Other services: tests, therapies, surgeries

Even with a generous plan, you could still face thousands of dollars in a bad health year — though most plans cap your maximum out-of-pocket (often $5,000–$9,000+).

Real-world example:

Last year I had a client with a $0 premium plan. He thought his heart procedure would cost almost nothing. Between the hospital copay, specialist visits, and rehab, he still paid over $4,000 out of pocket that year.

Bottom line:

Zero-premium plans can be great if you’re healthy and stay in-network. But they shift costs from monthly premiums to when you get care. That’s why we always look at your total estimated costs — not just the flashy promise of a $0 premium.

Answer: “How will this plan work for me if my health changes significantly in the next 5–10 years?”

Most folks shop Medicare based on today’s health, doctors, and costs. But life happens — new diagnoses, surgeries, chronic conditions, or just plain aging. That’s when the real regrets show up:

*Medicare Advantage networks can shrink or drop your specialists.

*Prior authorizations and denials often increase.

*Out-of-pocket costs can explode even with “good” plans.

*Switching back to Medigap later can be denied or become very expensive if you’re no longer healthy.

Answer: No, you likely didn’t make a mistake. Traveling a lot makes Original Medicare + Medigap one of the smartest choices. You get to see any doctor or hospital in the U.S. that accepts Medicare — no networks, no restrictions when you’re on the road. That peace of mind is worth a lot.

That said, here' how to possibly lower those rising premiums:

*Shop different insurance companies for the same Medigap plan (G, N, etc.) — rates vary a lot.

*Consider a High-Deductible Plan G if you’re healthy.

*Check for spouse discounts or multi-policy savings.

*Review your Part D drug plan separately for extra savings.

Quick warning: Switching from Medigap to a Medicare Advantage plan is easy now, but going back later can be hard and/or costly if your health changes.

Ultimately you bought flexibility and protection for your lifestyle. That’s rarely considered a regret.

Answer: The most common regrets I hear from folks who’ve been on Medicare for a while:

*Missing the initial guaranteed-issue period for Medigap

*Delaying a supplement plan can make it unavailable or much more expensive later — and they’ll ask about your health.

*Signing up late for Part B or Part D (This triggers lifelong penalties that never go away.)

*Picking a plan just because it has the lowest premium (It often ignores total costs, coverage gaps, doctor networks, and what happens when you actually get sick.)

Bottom line: your Medicare choice should consider your health today AND in the future — not just today’s cheapest price.

✅ Review everything carefully during your Initial Enrollment Period (around age 65).

✅ Compare Original Medicare + Medigap + Part D vs. Medicare Advantage plans.

✅ Talk to an independent advisor (not one who only sells one company’s plans).

✅ Check your plan every year during Open Enrollment (Oct 15 – Dec 7) because plans change.

Answer: No, Original Medicare (Parts A and B) does not cover stairlifts or other home modifications — even if your doctor recommends one for safety or to prevent falls. Medicare considers stairlifts/chairlifts to be permanent changes to your home, not medical equipment. Only certain durable medical equipment, called DME, is covered. This includes items like wheelchairs, walkers, hospital beds, and patient lifts that help you move from bed to chair. These items are reusable and meant mainly for medical needs. Because a stairlift is attached to your stairs or walls, Medicare does not cover it.

*Alternatives for funding if you're exploring options for a stairlift:

-Check Medicaid (varies by state; some waivers or programs cover home modifications for eligible low-income individuals).

-Look into VA benefits (for veterans with service-connected disabilities).

-Explore local aging agencies, nonprofit programs, grants, or manufacturer financing.

Answer: Starting dialysis for End-Stage Renal Disease (ESRD) makes you eligible for Medicare regardless of your age, as long as you meet the other work history benefit eligibility requirements. It's one of the few conditions allowing Medicare eligibility under 65 without waiting through a disability waiting period.

If you’re already on Medicare, starting dialysis doesn't change your eligibility. Your existing coverage starts paying for dialysis services immediately. However, if you're not on Medicare, you become eligible due to ESRD. You must apply through Social Security, coverage can be retroactive up to 12 months before the application.

NOTE: When Coverage Ends (If Only Eligible Due to ESRD)

12 months after the month you stop dialysis.

36 months after a successful kidney transplant.

Part B can continue longer for immunosuppressive drugs in some cases. Coverage can resume if dialysis restarts or other qualifying conditions are met.

Answer: Unless specifically excluded coverage is generally based on medical necessity. Contrary to popular belief services are not considered medically necessary simply because your provider says so--for any given procedure there are specific medical necessity guidelines that must be met in order for your services to be approved. If your procedure was denied due to lack of medical necessity you should have your provider collect the medical necessity guidelines from their provider representative at the insurance carrier and appeal the claim with documentation showing that all prerequisite guidelines have been met.

Answer: There is no Medicare exclusion preventing you from getting a CT scan simply because you turn 78. Medicare covers CT scans regardless of age whenever they are considered medically necessary for diagnosis, monitoring, or treatment of a condition. The confusion likely comes from low-dose CT (LDCT) lung cancer screening, a very specific preventive service. Medicare Part B covers annual LDCT lung cancer screenings but only if you meet all these criteria:

You are between ages 50 and 77.

You have no signs or symptoms of lung cancer.

You have a smoking history of at least 20 pack-years (e.g., one pack a day for 20 years, etc.).

You currently smoke or quit within the last 15 years.

A doctor orders the screening after shared decision-making.

Answer: Original Medicare and Medicare Supplements do NOT include dental and vision coverage, you would need to pair them with stand-alone dental/vision products. If you want a Medicare policy that INCLUDES dental and vision you will need to explore your available Medicare Advantage options.

Answer: The worst Medicare-related mistake someone can make is to go through the process of picking a policy without the guidance of someone who fully understands the implications. Why risk making an uninformed decision when it doesn't cost you anything to consult an agent?

Answer: The first thing you should do when you receive your Annual Notice of Change is simply review it. It will be a side by side comparison of your current coverage versus the coverage you will have the following year should you decide to remain in the plan. It's the single best way to stay informed about changes in your policy from year to year. If you see anything that concerns or confuses you then reach out to your agent. If you're okay with the changes you see then just do nothing and the policy will be rolled over to the following year automatically.

NOTE: If a plan is not renewing, or is exiting your market entirely, the plan does not send a standard ANOC because there are no "changes" to describe for a plan that won't exist next year. Instead, the plan is required to send a separate non-renewal or termination notice to affected enrollees. This notice informs you that the plan is ending, explains what happens next (e.g., whether you'll be automatically enrolled/"mapped" into another plan offered by the same company, or if you'll be disenrolled). If you receive one of these notices you should immediately set up an appointment with your agent during the Annual Enrollment Period (Dates: 10/15–12/7) or a Special Enrollment Period if applicable.

Answer: Original Medicare does cover cataract surgery itself under Part B, including removing the cloudy lens and implanting a replacement intraocular lens (IOL), as long as it's medically necessary (e.g., the cataracts affect daily activities like driving or reading).

As long as the medical necessity requirement is met Medicare covers a standard monofocal IOL. This is a basic man-made lens that usually corrects vision at just one distance (usually far vision). The surgery and the basic lens are covered after the Part B deductible (currently $283), you will also pay a 20% coinsurance of the Medicare-approved amount.

Original Medicare does NOT cover premium or advanced IOLs. This includes options like: Multifocal lenses for seeing at multiple distances without glasses,

Toric lenses that correct astigmatism, or other specialty lenses that reduce or eliminate the need for glasses/contacts.

If your friend chose one of these premium lenses then Medicare pays for the surgery and the cost of a standard lens, but she is responsible for the additional out-of-pocket cost of the upgraded lens itself. This can range from $1,000–$4,000+ per eye, depending on the type and provider—it's considered an elective upgrade, not medically necessary under Medicare rules.

PLEASE NOTE:

* Medicare also covers one pair of standard prescription eyeglasses or contact lenses after the surgery with an IOL implant.

*Coverage can vary slightly if your friend has a Medicare Advantage plan (Part C) instead of Original Medicare. Some MA plans may offer partial coverage for premium lenses but most follow similar rules to Original Medicare. It's best practice to check with the specific plan/provider for details.

Answer: Patience and reliability. Medicare clients are usually more patient with the process and not in as much of a hurry as the under 65 crowd. They tend to follow through with things better than their under 65 counterparts as well. It also seems that once they find a agent they appreciate their loyalty to keeping their business with that agent is much higher.

Answer: Virtual appointments can be convenient for some but prove technologically challenging for others. There are many steps of the process that require technical aptitude. Sometimes it's just easier to have an in-person meeting than to have one over the phone--for those who are hard of hearing visual aids can make the process much easier.

NOTE: for the especially old-fashioned sort it's nice to be able to look your agent in the eye and make an assessment of their trustworthiness in person.

Answer: All cases are different but most people are not financially prepared to pay the cost for both the Part B premium AS WELL AS the Medigap premium. That being said, some medical conditions can be even more costly under a Medicare Advantage plan before all is said and done so it is a good idea to do a medical needs and cost analysis to determine if there are any compelling reasons for them to choose one plan over the other.

Answer: One of the most common misconceptions about Medicare is that it is going to be provided at no cost to the enrollee. Many people assume that since they've paid into the system for years Medicare will be completely free once they turn 65. Part A is premium-free for most people who worked full time is the USA for at least 10 years but Part B always comes with a monthly premium.

NOTE: Part B premiums MAY be paid for some of those that are considered "Dual Eligible" for both Medicare and Medicaid.

Answer: Much the same way you would eat an elephant--slowly, one bite at a time. The process of signing up for Medicare can be extremely tedious even under the best of circumstances and it's easy to get bogged down by the minutia if you try to absorb the whole process at once. I take as much time as is necessary to walk my clients through the process one step at a time so that the experience isn't quite so overwhelming.

Answer: A lot of seniors have a hard time with technology. The most common frustration my clients face is the online identity verification process required by the government when initially signing up for Medicare. Calling Social Security to enroll is also an option but you should expect to sit through a potentially lengthy hold which can be very frustrating in it's own way.

Answer: PPO Plans offer flexibility but that flexibility comes at a price. There are some notable disadvantages when compared to plans like HMOs or EPOs. Some of the main disadvantages of PPO plans are as follows:

1. Higher Premiums: PPO plans typically have the highest premiums, often significantly more than HMOs or EPOs

2. Higher Out-of-Pocket Costs: This includes higher deductibles (the amount you pay before your coverage kicks in), copays, and coinsurance.

3. More expensive out-of-network care — While PPOs provide some coverage for out-of-network providers you will usually pay substantially more for those services. Expect much higher coinsurance, separate deductibles, or reduced reimbursement rates. In some cases, you may be required to pay upfront and file claims for reimbursement on your own. NOTE: Out-of-network providers are not required to write off excess charges like in-network providers are and you can be held liable for them.

4. More Responsibility Managing Personal Care: Without referrals or a designated primary care physician helping coordinate care you're mostly on your own to track provider network status, surprise bills, and handle potential paperwork/claims for out-of-network visits.

NOTE: In recent years PPO options have been disappearing in certain markets (e.g., Medicare Advantage, ACA Marketplace). Networks may be shrinking in some plans and overall costs continue trending higher due to overwhelming administrative costs and fraud. PPOs remain popular for those who value choice, like frequent travelers, those with established out-of-network specialists, or anyone wanting to see specialists without referrals. The trade-off is typically higher, less predictable expenses. If cost control or more predictable payments matter more then you should consider an HMO or EPO.

Answer: I've held several different positions in the health insurance industry over the years. The best part about being an independent health insurance broker is that I get to use my talents to help my clients manage a very difficult process and I don't even have to charge them for it. It's nice being able to do whatever is best for my client rather than whatever is best for the insurance company I would otherwise be employed at. I much prefer representing the individual as opposed to the insurance company.

Answer: People who have drawn Social Security Disability (SSDI) for at least 2 years are eligible for Medicare even BEFORE turning 65. Enrollment generally occurs in the 25th month of receiving SSDI, usually providing Parts A and B automatically. To be eligible for Part A at no additional cost you must have worked full time in the USA for at least 10 years. If you have NOT drawn SSDI for at least 2 years then you can enroll in Medicare anytime in the 3 months before your 65th birthday month, and up to 3 months after. If you don't enroll in a timely manner then there could be lifetime penalties assessed to your premiums. If you're still confused that's what I'm for, I'd be happy to guide you through the process.

Exceptions: The 24-month waiting period is waived for those with Amyotrophic Lateral Sclerosis (ALS) or End-Stage Renal Disease (ESRD)

Answer: Firstly, a professional consultation doesn't cost you anything-- why not have a professional help guide you through the process? Signing up for traditional Medicare when the time comes can be extremely confusing and aggravating. There are dozens of Medicare Supplement and Medicare Advantage plans available in any given region so unless you are well versed in the intricacies of health insurance it can be exceedingly difficult to make a well informed decision on your own. Also, making the wrong decision on a fixed income can be a costly mistake, sometimes negatively impacting your quality of life moving forward. Furthermore, if you call an insurance company directly they will tell you about the best plan that THEY have to offer but will not tell you if a competitor has something that is even better. An independent broker represents YOU, as opposed to the insurance company, and will help align you with the product that best meets YOUR needs.