Justin Lester, Medicare Insurance Broker

Answer: A Private Fee-for-Service (PFFS) Medicare Advantage plan is a type of Medicare Advantage plan offered by a private insurance company. The plan determines how much it pays doctors and hospitals and how much you pay for medical services.

Can your doctor refuse to accept it? YES!

Unlike some other Medicare Advantage plans, a doctor who is not part of a PFFS plan's network can decide whether to accept the plan's payment terms.

Here's what you should know:

Your doctor can accept the plan for one visit and decline it at a future visit.

You do not need a primary care physician or specialist referrals.

Some PFFS plans have provider networks, while others don't.

You may pay more when using an out-of-network provider.

Some plans allow additional balance billing.

Emergency care is an exception; providers must treat you in an emergency.

My advice: Before enrolling in a PFFS plan, check with your doctors and hospitals to make sure they accept the plan. Don't assume that accepting Medicare means they automatically accept every Medicare Advantage plan.

Answer: Yes! Medicare Part D plans are required to cover most HIV medications because they belong to a protected drug class.

However, plans can make certain formulary changes, so it's important to review your coverage each year. If a medication is affected, you may have options such as exceptions, appeals, and temporary transition supplies.

My advice: Never assume your medication will automatically remain covered. Check your plan before making a change, and never stop treatment without talking to your doctor.

Answer: What about 2027 estimates?

Part A: Approximately $1,788.

Part B: Estimates vary, with some projections around $292–$310.

These are projections, not official Medicare figures.

Important for Medicare Advantage members: These deductibles do not necessarily apply directly to your plan. Medicare Advantage plans establish their own cost-sharing arrangements.

My recommendation is to review your 2027 plan's hospital and medical costs before enrolling.

Answer: A $0 premium doesn't mean free healthcare. You may still pay your Medicare Part B premium, copays, deductibles, and out-of-pocket costs.

Before enrolling, make sure your doctors are in-network, your prescriptions are covered, and you understand your hospital costs.

My advice? Don't choose a plan just because it says $0 premium. Choose one that fits your healthcare needs and budget!

Answer: The biggest difference is really how the coverage works alongside Medicare.

Supplemental insurance, like a Medigap plan, is designed to help pay some of the costs that Original Medicare doesn’t cover, such as deductibles, coinsurance, and copays. Medicare pays first, and the supplement helps with the remaining costs depending on the plan.

Secondary insurance is a broader term. It simply means another insurance plan that pays after Medicare. A Medicare Supplement is one type of secondary coverage, but other types of insurance can also be secondary.

So, in simple terms: Medicare is primary, and the secondary/supplemental coverage helps pick up costs Medicare doesn’t pay. The important thing is understanding exactly what type of plan you have and how it coordinates with Medicare.

Answer: I start by keeping it simple and explaining Medicare step-by-step. I focus on their specific situation, answer questions, and make sure they understand their options before making any decisions. My goal is to educate first and help them feel confident about their coverage.

Answer: The best way is to check directly with your Medicare plan or Part D provider. They can confirm if the medication is covered, what tier it falls under, and what your cost will be. You can also ask your pharmacist to verify coverage before filling the prescription.

Answer: Be patient, listen to their concerns, and include them in every decision. Help them compare their options, explain things in simple terms, and encourage them to ask questions. The goal is to help them feel informed and confident, not pressured. Working with a local agent can be a wonderful solution to this.

Answer: Medicare Advantage plans aren't truly free. Many have a $0 monthly plan premium, but you must still pay your Medicare Part B premium, and you'll usually have copays, coinsurance, and other out-of-pocket costs when you receive care.

Answer: Yes, for many people. The 2025 Medicare Part D changes include a $2,000 annual cap on out-of-pocket prescription drug costs, which can significantly reduce expenses for those taking high-cost specialty medications. You may also have the option to spread those costs over the year instead of paying large amounts all at once.

Answer: The best way is to make sure that you understand your MA's network and whether that doctor/lab is in network. It could also be a great idea to ask your doctor if prior authorization is needed and to check your insurance so you know what, if anything, you'll owe.

Answer: What I enjoy most is helping people understand their options and giving them confidence in their decisions. Medicare can be confusing, and it's rewarding to make the process simple while helping clients find coverage that fits their needs and budget.

Answer: Original Medicare was originally designed to cover major medical expenses, but unfortunately not every healthcare cost, such as dental, vision, hearing, cosmetic surgeries, long-term care, etc.

That's why there are deductibles and coinsurance. Many people fill those gaps with a Medicare Supplement plan, Part D plan, hospital indemnity, cancer plan, long-term care plan and sometimes replace Original Medicare with a Medicare Advantage (Part C) plan.

Answer: Medicare is consistent with one thing more than anything else, and that is simply change. While the lawmakers sometimes propose changes to Medicare funding, your coverage doesn't get cut automatically. If changes are ever made, you'll be notified and have time to review your options with one of our local agents.

Answer: The best strategy is to make the meeting personal; start asking questions about their plans for retirement and goals they may have. Make them heard. Speak clearly and maintain eye contact through the camera.

Answer: My agency helps our clients apply for the Medicare Savings Program at the state level. We are not able to guarantee whether or not they qualify for the MSP, but we do assist in applying for it.

Answer: It depends. Most retired federal employees keep their FEHB coverage, but many still enroll in Medicare Part A because it's usually premium-free. Whether to enroll in Part B depends on their health needs, costs, and how they want FEHB and Medicare to work together. It's worth reviewing your options before deciding.

Answer: If the bills involve Medicare-covered services, Medicare payments should generally be reflected in the provider's billing records. If they aren't, it could mean the claims were never submitted. Request a debt validation and ask the original provider for any itemized billing statements covering 2017-2024. If you believe the claims were processed incorrectly or you need help understanding what was paid, I'd refer that you call Medicare directly.

Answer: To be provided straightforward and honest guidance without having to rely on one insurance company and their plans, to be given a pathway to personalized recommendations.