Jim Carroll, Medicare Insurance Broker

Answer: Bipolar Disorder is one of the 15 Specific Chronic Conditions under the Centers for Medicare and Medicaid Services (CMS) Chronic Condition Special Needs Plans (C-SNP).

A C-SNP is a Special Needs Medicare Advantage (MA) Plan. Original Medicare Part A and Part B only cover 20% of medical costs. A C-SNP MA plan is designed to provide additional benefits to meet the chronic needs of its members.

This is why it's wise to have a Nationally Licensed Health Insurance Broker who is a Medicare Special Needs expert do a Health Risk Assessment with you. They will be able to find the best C-SNP plan in your area that will meet your health and financial needs. Although January 1 through March 31 is Medicare Open Enrollment, when people can change from one MA plan to another, anyone eligible for a C-SNP can enroll at any time of the year.

Once someone is enrolled into a C-SNP, all that's needed to finalize the enrollment if for the doctor who diagnosed and is providing treatment for the chronic condition to complete a verification form of said diagnosis/treatment within 30 days of the enrollment. Otherwise, CMS will decline the enrollment.

Answer: The only way to give a definitive answer is to look at your plans Summary of Benefits (SOB). You can get this either on your insurance carrier’s member portal or a Google search of your plans Summary number that’s on your insurance card.

The SOB will list both in and outpatient surgery benefits, and your deductible and maximum out of pocket (OOP).

Bottom line is your max OOP is the most you will have to pay if the surgical bills exceed that amount.

Answer: It’s not if you made a mistake, but how you use the insurance. Granted, most MA plans have a $0 monthly premium. Most have at least a few thousand dollars in deductible and more in maximum out of pocket costs.

If you only see a doctor when you’re sick or injured, a higher copay might not be a bad trade off if you have less than $5,000 maximum out of pocket and something lands you in the hospital.

On the other hand, if you’re seeing multiple specialists, higher copays will add up quickly, and generally don’t count towards your deductible.

Speak to a licensed health insurance broker to have a Health Risk Assessment done with a thorough overview of your current MA plan. It will be no charge and give you peace of mind.

Answer: The Centers for Medicare and Medicaid Services (CMS) requires Agents and Brokers to get certified every year to sell Medicare. And, each insurance carrier requires their own annual certification.

It’s always a wise choice to do an annual review of your health and life benefits. The health insurance plan you currently have might not be what you need for the upcoming year.

Having a certified, licensed agent or broker will be able to do a needs analysis with you so you don’t end up in a plan that will leave you financially vulnerable if a medical crisis happens.

Answer: If you have one or more of the specific severe or disabling chronic conditions as defined by the Centers for Medicare & Medicaid Services (CMS), you may qualify for a Medicare Advantage Chronic Special Needs Plan (C-SNP). I advise speaking with a licensed broker to find out if you qualify.

If your rare disease is not on the list, but you could receive Medicaid, you may still qualify for a Dual Special Needs Plan (D-SNP).

Answer: Here are several scenarios to your benefit:

1. If you are on a Medicare Medicaid Dual Special Needs Plan now, your coverage will continue seamlessly.

2. If you have a Chronic Condition that's listed on the CMS website, you are eligible Right Now to enroll in a Chronic Condition Special Needs plan (C-SNPs). I can help you with that.

3. Also, if you have a Dual Eligible Special Needs Plan (D-SNP) available in your area, you can make changes to your coverage once a calendar month, which will go into effect ton he 1st day of the following month.

Answer: The spouse of a man who had Original Medicare Parts A and B, and was very ill contacted me for help. The man had developed a chronic condition that is listed under one of the 15 categories designated by Centers for Medicare & Medicaid Services. Medical bills were foreseen to stack up quickly.

The woman asked if I knew how she could get Medicaid for her husband. In addition to explaining how and providing the website, I help enroll him into a Medicare Advantage Chronic Special Needs Plan (C-SNP). The insurance company sends a chronic condition verification form to the primary care physician. Once the form is faxed back, the plan is approved and the goodness starts to happen.

C-SNPs are tailored to help the client with their specific medical needs, and assigns them a Care Coordinator from the insurance company. Typically, there are very minimal out-of-pocket expenses with these plans. And, many even have a Medicare Part B giveback, which means that a portion of the $185 monthly premium for Original Medicare Part B that is deducted from a person's Social Security Check each month is returned.

My client's wife had no idea these type of plans were available, and I was so happy to help alleviate the medical and financial burden from them.

Answer: Insurance carriers are for-profit companies. Their Medicare Advantage plans make money by spending less on a member's healthcare than the government payments they receive from Medicare. So, the more people they enroll, the more money they make.

The Centers for Medicare & Medicaid Services (CMS) has strict restrictions and guidelines on what insurance companies, agencies, and agents/brokers can and cannot advertise.

Unfortunately, many agencies and marketing firms slip in phrases like, "if eligible", and, "qualified members" with their ads. This is especially true when pushing Over the Counter (OTC) cards that can be used to pay for groceries.

I personally have had dozens of calls from seniors asking how they get their $[insert 4-digit number] check? I've had to explain that some ads walk the fine line using phrases that make it seem like people are entitled to big dollar checks, rebates, and even free dental coverage.

Bottom line is the are legal, provided they don't flat out say something that is definitely untrue (which is why they qualify with those phrases like "if eligible" and "qualified members" to enroll as many people as possible.

This is why it's wise to use a licensed health insurance broker who is certified to sell Medicare Advantage plans (like me) instead of going through Medicare.gov or an insurance agency where you talk to an agent in a call center who has quotas to meet.

Answer: Too many seniors tell me they want a Medicare Advantage Plan because they are on a fixed income and the plan is "free". It's not free.

Yes, most have a $0 monthly premium. But, if a senior is not healthy, the money is quickly spen on:

Office visit copays for specialists

Diagnostic tests

High-tier prescriptions

Deductibles

The amount you pay once you meet your deductible until you reach the Maximum Out-Of-Pocket (which you might never reach every year)

So, a Medicare Advantage Plan will only save money in the long run if it is one with a Part B giveback and it's never used for anything beyond preventative care (colorectal cancer screenings, women's visits, etc.). Otherwise, without an additional indemnity policy that covers the deficiencies of an Advantage Plan, the unexpected expenses can add up fast.

Answer: It's absolutely the 20 percent coinsurance gap that Original Medicare does not cover. Several examples of "too late" would be heart attack and cancer.

If you only have Original Medicare Parts A and B; or even a Medicare Advantage Plan with a high deductible and maximum out-of-pocket (deductible is what you must pay before the insurance starts paying 80 percent, and max out-of-pocket is the dollar amount you must pay before insurance pays 100 percent).

Heart Attack: When you get rushed to a hospital, the doctors don't stand around waiting to find out how much your insurance will pay. They save your life, get you stable, and the hospital sends you home. If you need additional treatment (bypass surgery, etc.), that's on you.

Cancer: It's too late to find out that your health insurance is horrible after you get a cancer diagnosis.

If you only have Original Part A and B, I suggest either a Medigap (supplement) or a Medicare Advantage Plan paired with a Hospital Indemnity policy to cover the big ticket hospital bills.

Answer: When I first got started in the Medicare world, I was a captive agent. In other words, I worked for a large national agency that only sold Medicare Advantage Prescription Drug Plan (MAPD). Back then, I thought MAPDs were the best thing since sliced bread because the plans typically had a $0 monthly premium.

As an independent broker I have the ability to better serve my clients with Medigap (a.k.a. Medicare Supplement Plans).

Doing the proper Health Needs Assessment shows me which plan is best for my client. If they have any health issues or simply enjoy traveling out of state, I always recommend a Medicare Supplement. That said, if they still insist on a MA or MAPD because of the $0 monthly premium, I strongly advise them to protect themselves from the unexpected expenses associated with high deductibles and out-of-pocket maximums by adding either a Hospital Indemnity plan or Out-of-Pocket protector plan.

Answer: It has been my experience that there are two reasons:

1. Even though most Medicare Advantage plans typically do not have a monthly premium, they do have other out-of-pocket expenses that people feel are either unwarranted or unfair. This is partly due to most seniors who have a Medicare Advantage plan are living on less income than when they were working. Therefore, the extra medical expenses are a pain point.

2. Medicare Advantage plans that are HMOs require members to get a referral from their Primary Care Physician to see a specialist. This additional step is perceived as a ridiculous waste of time and copay.

Answer: I'd say that they are not alone in that feeling. I have a client who told me, "Medicare is confusing - and with all of my medical conditions, I don't need confusing".

Anyone selling Medicare products (except Supplements) must complete a required annual certification based on compliance rules set by the Centers for Medicare & Medicaid Services (CMS), and certification training from each insurance carrier they want to represent.

I completely understand how it's overwhelming. But I am here to make sure that every one of my clients are protected based on their health needs while not being stretched past their budget.

Answer: Yes, you will eligible for a Special Enrollment Period (SEP) to enroll into a different MAPD plan.

Losing eligibility for the C-SNP triggers the SEP, which begins when you are notified of your disenrollment.

Answer: Full disclaimer: People who either enroll into a Medicare Advantage Plan or buy a Medicare Supplement [member] will never pay a commission to a broker, captive agent, or in-house agent. The insurance company pays the commission - even if you self-enroll through a link in Medicare.gov or an insurance company's website.

Differences:

Medicare Broker: A self-employed licensed agent. Although I am affiliated with an agency to use their resources, I do not work for them. I am an independent broker who contracts with the insurance carriers [company] I want to, and sell both Medicare Advantage Plans and Medicare Supplements. A Broker has their own book of business, builds a lasting report with their clients and provides excellent customer service.

Medicare Agent: An employee of an agency (otherwise known as a Captive Agent), who only sells the Medicare Advantage Plans of insurance carriers the agency contracts with. Also, the agency gets the lion's share of the commission and typically pays the agent an hourly wage plus a small percentage of the commission. They can work remote or in an office building in a call center environment, taking inbound calls to enroll members. And, they have sales quotas to meet.

In-house Agent: An employee of an insurance company who typically works in a call center taking inbound calls to enroll members.

When you experience the broker difference, you will know it.

Answer: My initial question is are you already on Medicare or are you planning ahead?

If you have not turned 65 yet or have and have no serious pre-existing conditions, a Medicare Supplement (a.k.a. Medigap plan) covers everything that Original Medicare Part A and Part B do not with only an annual deductible of $257, and no other surprise out of pocket expenses.

Answer: How old are you?

For clarity, when exactly did you lose SSI? You have 3 months to join a Medicare Advantage Plan from either the date you lost Medicaid or the date you were notified that you're no longer eligible, whichever is later.

Also, regardless if you lost SSI, if your disability is due to one or more of the chronic conditions recognized by Centers for Medicare & Medicaid Services (CMS), you would qualify to join a Chronic Condition Special Needs Plans (C-SNPs). Those chronic conditions are:

Chronic alcohol and other dependence

Certain autoimmune disorders

Cancer (excluding pre-cancer conditions)

Certain cardiovascular disorders

Chronic heart failure

Dementia

Diabetes mellitus

End-stage liver disease

End-Stage Renal Disease (ESRD) requiring dialysis (any mode of dialysis)

Certain severe hematologic disorders

HIV/AIDS

Certain chronic lung disorders

Certain chronic and disabling mental health conditions

Certain neurologic disorders

Stroke

Answer: The only income question on Medicare.gov "Estimate when I'm eligible for Medicare" page asks, "Have you worked at least 10 years for which you paid Medicare taxes?". https://www.medicare.gov/eligibilitypremiumcalc#/eligibility

A high income earner might pay more than the standard Part B premium. The amount is based on your modified adjusted gross income on your IRS tax return from 2 years prior to the current plan year. For 2025, the threshold for an individual tax return is $106,000 and $212,000 for a joint tax return. https://www.medicare.gov/publications/11579-medicare-costs.pdf

Answer: Blunt but honest; sometimes you really do get what you pay for. Insurance companies are businesses, and receive a monthly payment from the Centers for Medicare & Medicaid Services. They would go out of business if they paid 100% of everything. That's why there's a give and take.

I tell my clients to think about a double-sided scale, like Statue of Justice holds. Imagine your monthly premiums are in one scale and the other side is empty. Your premiums make the scale go down. Then, put everything else you have to pay (deductible, 20% coinsurance, and maximum out-of-pocket) on the other side. What happens? The more you add to one side, it goes down and the other side goes up.

Unfortunately, people look at the immediate benefit of not having a monthly premium and don't weigh the extra costs of the plan that are shown in the Summary of Benefits. This is why a needs assessment is so important. Deciding whether to enroll in a Medicare Advantage plan or a Medicare Supplement depends on you health and how much you will spend on medical care for the entire year.

Medicare Advantage Plan (average costs for easy math)

Monthly Premium: $0

Part B Premium (what comes out of your monthly Social Security check): $185x12= $2,200

Annual Deductible: $5,000

Coinsurance: 20% until you reach your Maximum Out-of-Pocket

Maximum Out-of-Pocket: $9,400

Dr. copays, 2 visits per year: $50

2 Specialist, 2 visits each per year: $200

TOTAL..................................................$7,470 (this is only factoring the Deductible and not Coinsurance to reach your Maximum OOP)

VS.

Medicare Supplement Plan G

Monthly Premium: $200x12= $2,400

Part B Premium (what comes out of your monthly Social Security check): $185x12= $2,200

Annual Deductible: $257

Maximum Out-of-Pocket: $0

Dr. copays, 2 visits per year: $0

2 Specialist, 2 visits each per year: $0

TOTAL..................................................$4,857

Answer: There are 3 types of Special Needs Plans (SNPs): Dual Eligible (D-SNPs), Chronic Condition (C-SNPs), and Institutional (I-SNPs). The most common are D-SNPs. These plans are just like Medicare Advantage Plans, but with extra benefits based on the member's specific needs.

D-SNPs are for individuals who qualify for both Medicare and Medicaid. The level of benefits received is based on either financial need, medical need, or both.

C-SNPs are for individuals who have at least one of the chronic conditions listed on the Centers for Medicare & Medicaid Services website https://www.cms.gov/medicare/enrollment-renewal/special-needs-plans/chronic-conditions. These plans often assign a care coordinator to the member to help manage their condition(s).

I-SNPs are for people living in institutions like nursing homes or requiring constant nursing care at home.

The insurance carriers will require proof that someone qualifies for a special needs plan when they enroll, such as their Medicaid number, a specialist doctor who is treating them for the chronic condition, or a letter from the nursing home.

Answer: Typically, when someone signs up for Original Medicare Part A and Part B, they check the box stating they want the Part B monthly premium to be deducted directly from their monthly Social Security check. The standard monthly premium for Medicare Part B in 2025 is $185.00.

Log in to your Medicare.gov account, and you will see the plan(s) you are enrolled in.

Answer: My general answer is that Original Medicare Part A and Part B are Never enough coverage.

Part A covers inpatient hospital stays, care in a skilled nursing facility, hospice care, and some home health care.

Relatively speaking, how much you consider is "enough" coverage depends on how much money you are comfortable spending on medical expenses.

Medicare.gov > Inpatient hospital care web page shows,

"You pay this in each benefit period (in 2025):

* Days 1–60: $0 after you meet your Part A deductible ($1,676).

* Days 61–90: $419 each day.

* Days 91 and beyond: $838 each day for each lifetime reserve day (up to a maximum 60

reserve days over your lifetime).

* Each day after you use all of your lifetime reserve days: You pay all costs.

https://www.medicare.gov/coverage/inpatient-hospital-care

https://www.medicare.gov/coverage/long-term-care-hospital-services

https://www.medicare.gov/coverage/inpatient-hospital-care/inpatient-outpatient-status

Answer: There are several misconceptions:

1. Medicare is free.

Fact: The cost of Medicare Part B is taken directly from your Social Security check.

2. Medicare Advantage Plans are free/have $0 monthly premiums.

Fact: Albeit there are Medicare Advantage Plans that do have $0 monthly premiums, people are often surprised to find they have doctor/specialist visit copays, annual deductibles, and maximum out-of-pocket costs. And, Medicare Advantage Plans only pay for the first 21 days in a skilled nursing facility.

Answer: Yes. This is why the first thing you are asked is to verify your zip code.

Health insurance companies use hundreds if not thousands of datapoints to determine what plans they offer in geographical locations.

If you move to a different zip code, it is critical you contact either your broker or agent, or insurance company if you self-enrolled. Otherwise, you might go to a new provider who doesn’t take your plan.

Think of it like this - Insurance companies have many types of plans, and the different types have specific nuances. Much like a car manufacturer has different models of vehicles, and each model has different trim levels.

Answer: Yes, if you qualify for a Medicare/Medicaid Chronic Special Needs Plan (C-SNP) for diabetes. The insurance carrier will assign a case person to help you find the nutrition counseling.

Answer: Absolutely. A Medicare Supplement Plan G covers 100% after you meet the $257 annual deductible. The reason this sounds so simple is because you are paying a monthly premium to a private insurance company. But, if you do the math, the 12 months of premiums are still less than the typical deductible and out-of-pocket maximums with a Medicare Advantage Plan. You can also add a Prescription Drug Plan usually a zero to little cost, depending on the Tier level of your medications.

Answer: Yes, certain Medicare Advantage Prescription Drug Plans (MAPDs) and Medicare Advantage Dual Eligible Special Needs Plans (D-SNP) (Dual = Medicare/Medicaid), will cover different chronic and severe asthma and breathing conditions. Depending on your geographic location and insurance carrier availability, there are deductibles, and out-of-pocket maximums to meet each year.

Also, a Medicare Supplement combined with a Prescription Drug Plan (PDP) is another viable option because if purchased when you are Medicare first eligible, it is guaranteed issue and there is only a $250 annual deductible.

Answer: A PPO allows you to choose any providers in-network, and generally don't require referrals for specialist. And, although you will pay more for services, you can go to an out-of-network provider.

In contrast, with an HMO, you must select a Primary Care Physician and see that provider before you are allowed to see a specialist. That said, no services will be covered if you go out of the insurance carrier's network except for medical emergencies if you are traveling out of your network area.

Answer: Would it be a bad idea to use the knowledge and experience of a licensed health insurance agent/broker who also has the annual Medicare certifications and insurance carrier trainings? It costs you nothing, but can gain you everything.

Although you may be completely comfortable choosing and self-enrolling into either a Medicare Advantage Plan or Medicare Supplement and Prescription Drug Plan, working with an certified agent/broker might mean the difference of you paying thousands of dollars more during the year by not having the knowledge of how different plans may or may not meet your specific medical needs. Can you afford to choose the wrong plan yourself and have a huge medical bill cause you financial hardship?