Ken Banks, Medicare Insurance Broker

Answer: No, Medicare does not cover 24/7 in-home supervision, around-the-clock care, or long-term personal care for dementia patients who wander. Medicare is designed to pay for acute medical care and short-term rehabilitation, not "custodial care," which includes continuous supervision, companion services, or assistance with basic daily living activities.

Answer: One of the most common and significant misconceptions people have about Medicare is that it is entirely free.

Answer: Medicare generally does not pay for long-term care (also known as custodial care), such as assistance with daily activities like bathing, dressing, or eating. Medicare only covers short-term, skilled nursing facility stays or home health care to improve a specific medical condition after a hospital stay. Because of this gap, planning ahead for these expenses is crucial.

Answer: In most cases, no. While the Annual Enrollment Period (AEP) from October 15 to December 7 allows you to leave a Medicare Advantage plan and return to Original Medicare, it does not provide a guaranteed right to buy a Medigap plan

Answer: Medicare primarily covers the patient, not the caregiver, but you may access support through your spouse's benefits.

Answer: Yes. Cost vary based on the plan and coverage options you may have. As well as facilities, where procedure is done.

Answer: There are stricter regulations on Medicare Advantage market and sales practices already in affect. It have stricter compliance safeguards to protect medicare beneficiaries.

Answer: Yes. It's very important to make sure your agent,if you have one, know if your specialist is in-network before you enroll into the plan. If they didn't, it's a disservice to you.

Answer: You can likely keep your current doctors if you switch to a Medicare Advantage (MA) plan, but only if they are in that specific plan's network, which often requires finding a plan that includes your providers; HMO plans are stricter (usually only in-network), while PPO plans offer more flexibility and out-of-network coverage at a higher cost, so always check your doctor's network status on the plan's website or Medicare.gov/care-compare before enrolling for non-emergency care.

Answer: Yes, most Medicare Part D prescription drug plans cover Repatha (evolocumab), an injectable medication for high cholesterol. However, specific coverage depends on your individual plan's formulary (list of covered drugs), and the plan may require prior authorization.

Answer: Yes, Guaranteed Issue (GI) rights for Medicare Supplement (Medigap) plans are available after your initial Medigap Open Enrollment Period ends, but only under specific, qualifying life events. These are different from the general Medicare Open Enrollment Period (October 15 – December 7) that applies to Medicare Advantage and Part D plans.

When Guaranteed Issue Rights Apply

Guaranteed issue rights mean that an insurance company must sell you a Medigap policy, cannot deny you coverage, and cannot charge you more due to your health status or pre-existing conditions.

Common situations that trigger a guaranteed issue right include:

Loss of Employer Coverage: You have Original Medicare and an employer or union group health plan (including COBRA) that is ending.

Loss of Medicare Advantage Plan Coverage: Your Medicare Advantage Plan's contract with Medicare ends, you move out of the plan's service area, or you lose coverage through no fault of your own.

Trial Rights: You enrolled in a Medicare Advantage Plan when you were first eligible for Medicare at age 65, and you decide to switch back to Original Medicare within the first 12 months (this is a one-time right).

Disrupted Medigap Coverage: Your Medigap insurance company goes bankrupt or terminates your policy without fault on your part.

Misleading Information: Your plan or insurer violated their contract or misled you about your coverage.

Answer: Whether your overnight hospital stay is covered "fully" by Medicare Part A depends entirely on your admission status (inpatient vs. outpatient observation) and the length of your stay. You will also have to pay a deductible and potentially daily coinsurance costs.

Key Factor: Inpatient vs. Observation Status

The crucial factor is not simply staying overnight, but whether your doctor formally orders you to be admitted as an inpatient.

Inpatient Status (Covered by Part A): If your doctor writes an order to admit you as an inpatient to treat your illness or injury, your stay falls under Medicare Part A. This covers your room, meals, general nursing, medications, and other hospital services.

Observation Status (Covered by Part B): If you are in the hospital for observation, even in a hospital bed overnight, you are considered an outpatient. These services are covered under Medicare Part B, which means higher potential out-of-pocket costs and no coverage for a subsequent skilled nursing facility stay unless you had a qualifying 3-day inpatient admission.

Answer: If you are unable to provide evidence of creditable coverage, the primary consequence is that you may face late enrollment penalties if you choose to enroll in Medicare Part B or Part D at a later date. These penalties are typically permanent and are added to your monthly premiums for as long as you have that coverage.

Answer: Twice per year. Oct. 15-Dec.7 Annual Enrollment Period then Open Enrollment Period Jan. 1-Mar. 31 follows.

Answer: The primary disadvantages of an HMO (Health Maintenance Organization) health insurance plan are its limited provider network, the need for referrals to see specialists, and no coverage for out-of-network care except in emergencies.

Answer: Whether a higher premium plan would have been better depends on your healthcare usage. Higher premium plans usually offer more predictable, lower costs per visit once the deductible is met.

Answer: You will be automatically enrolled a d switched over to Medicare but it's a great idea to call and verify everything is done in your behalf for Parts A and B of Medicare.

Answer: A Medicare annual wellness visit includes a health risk assessment, review of medical and family history, and the creation of a personalized prevention plan. It is not a physical exam, but the provider will take routine measurements like your height, weight, and blood pressure, and will screen for issues like cognitive decline. The visit helps create a schedule for future screenings and immunizations, discuss lifestyle factors like diet and exercise, and plan for advance care.

Answer: You will not have to pay a penalty if you are covered by your wife's employer's group health plan, provided it has 20 or more employees. You can delay Part B enrollment until your wife retires without a penalty, and will have an 8-month Special Enrollment Period to sign up once her coverage ends.

What you can do now

Keep Part A only for now: Since you are eligible for premium-free Part A and have other coverage, you can keep it and delay Part B to avoid paying premiums on both.

Notify Social Security: Before your 65th birthday in August, contact the Social Security Administration to let them know you are delaying Part B because you have other creditable coverage through your wife's employer.

Verify employer size: For this to be a "no-penalty" delay, your wife's employer must have 20 or more employees. If it has fewer than 20 employees, you may face a late enrollment penalty.

What to do when your wife retires

Enroll during the Special Enrollment Period (SEP): When your wife retires, her employer coverage will end, and you will have a Special Enrollment Period (SEP) to sign up for Part B.

Understand the SEP timeframe: The SEP begins when the employer coverage ends or she stops working, whichever comes first, and lasts for 8 months.

Avoid penalties: As long as you enroll within this 8-month SEP, you will avoid the Part B late enrollment penalty. The penalty is typically 10% of the monthly premium for each full 12-month period you could have enrolled but didn't.

Answer: Expanding Medicare to younger Americans has potential benefits and drawbacks for the program, the healthcare system, and taxpayers, depending on how such a policy would be designed and implemented.

Answer: Just picking the cheapest Medicare plan is a risky strategy because the cheapest monthly premium often comes with trade-offs like higher out-of-pocket costs, limited provider choices, and less comprehensive coverage. A plan that seems inexpensive could lead to much higher total healthcare costs if you need frequent or specialized care.

Answer: Call me now! I'll be more then happy to help you navigate the confusion of Medicare.

Answer: Yes, Medicare star ratings are meaningful for the care you will receive as they measure a plan's quality based on member experience, customer service, and performance in areas like preventive care and chronic condition management. A higher rating indicates a higher-performing plan, but it's crucial to also check that the plan has your specific doctors and prescriptions in-network.

Answer: Medicare coverage for your stay in a skilled nursing facility ends when your need for rehabilitative care stops. Long-term custodial care, which involves help with daily activities like bathing and dressing, is generally not covered by Medicare and is not considered rehabilitative. Your coverage will stop once the facility determines you have reached a point where you are not making progress, will not improve your condition, or are not participating in therapy. At that point, you are responsible for costs, which can be paid privately, or you may qualify for other programs like Medicaid.

Answer: Yes, UnitedHealthcare Medicare Advantage plans generally cover medically necessary occupational therapy, but there are important requirements. Since September 1, 2024, most outpatient occupational therapy requires prior authorization from UnitedHealthcare, though there are some exceptions. The therapy must be ordered by a doctor and provided by a qualified professional in an approved setting.

Answer: For high-cost diabetes medication, the best choice between a standalone Part D plan and a Medicare Advantage plan depends on your specific drugs, preferred pharmacies, and overall healthcare needs. Some Medicare Advantage plans may offer lower overall costs or more integrated benefits, while standalone Part D combined with Original Medicare provides greater flexibility in choosing your doctors.

Answer: Yes, your cholesterol medication counts toward your Medicare Part D out-of-pocket spending, which is a key component for progressing through the coverage stages. As of 2025, the "coverage gap" or "donut hole" has been eliminated and replaced by a new $2,000 annual out-of-pocket spending cap. Once you hit this cap, you will enter catastrophic coverage, where your covered medications will have no copayments or coinsurance for the rest of the year.

Answer: If you're on a state health retirement plan or Medicare Supplement plan with a chronic illness that consists of alot of doctor's visits.

Answer: Explain in detail what Medicare is and all the parts. Take them through all the steps and educate them on the pros and cons of it all.

Answer: They can't answer all your questions or concerns. Also they can't provide you with the services you may need.

Answer: You can call your agent if you have one, your insurance provider or me! You can also go to your insurance provider's website to look up healthcare providers.

Answer: You are likely paying more for Medicare Part B and Part D than your friends due to the Income-Related Monthly Adjustment Amount (IRMAA), a surcharge added to premiums for beneficiaries with higher incomes. The purpose of IRMAA is to ensure that higher-income beneficiaries contribute more to the cost of their Medicare coverage.

Answer: Part B has a monthly premium billed to you by Medicare. You chose to pay premiums yourself initially: Even if you receive Social Security, you may have been billed directly for the premiums. These payments can then be automatically deducted from your Social Security check going forward.

Answer: Make sure your doctor is a Medicare Provider and make sure you're in the right Medicare plan. The key difference is that your friend likely had a free Annual Wellness Visit, while you received a more comprehensive Annual Physical Exam, which is not covered by Original Medicare. The charges you incurred were probably for the physical exam and any additional services performed.

Annual Wellness Visit vs. Annual Physical Exam

Feature Annual Wellness Visit (AWV) Annual Physical Exam

Coverage covered 100% by Original Medicare under Part B, with no copayment or deductible. Not covered by Original Medicare. Patients are responsible for 100% of the cost.

Purpose: A preventive "planning session" to develop or update a personalized plan to prevent disease and disability. It is not an exam to diagnose or treat specific illnesses. A comprehensive, "hands-on" exam to check your current overall health. It focuses on diagnosing and treating medical conditions.

Procedures include routine measurements like height, weight, and blood pressure, plus:

• A health risk assessment

• Review of medical and family history

• Review of current providers and prescriptions

• Screening for cognitive impairment includes a physical examination, often with:

• Vital signs check

• Lung, heart, and abdominal exams

• Screenings and lab work (e.g., blood tests, X-rays) to check for health problems

Additional Costs You may be billed if your doctor addresses a new or existing medical condition or orders labs and tests during the same appointment. All costs are out-of-pocket unless you have a separate plan (like a Medicare Advantage plan) that covers them.

Why you may have been billed

You requested a physical: Your doctor's office may have scheduled you for a full annual physical exam when you asked for an annual check-up, instead of the Medicare-covered wellness visit.

You discussed a specific health problem: Even if you scheduled an AWV, you would be billed if you used the visit to discuss or receive treatment.

Answer: Only if they're not looking out for your best interests and needs. Working with a Medicare broker or agent can be helpful, but there are potential disadvantages to consider, including conflicts of interest, limited plan options, and sales tactics that might not serve your best interests. It's important to understand the distinctions and potential issues to make an informed decision.

Answer: Medicare Part B, also known as Medical Insurance, is optional and helps cover medically necessary services and preventive care. It covers services like:

Doctor visits: Certain doctor services and outpatient care

Durable medical equipment: Wheelchairs, walkers, and hospital beds

Preventive services: Screenings, vaccines, and yearly wellness visits

Mental health services: Therapy and chiropractic care

Prescription drugs: Some anti-cancer, immunosuppressant, and dialysis drugs

Answer: Your Healthcare company will never call you to update your plan. If you can't call the number back and get the same person be very cautious. Best rule is to stick with a one good agent as myself and never switch with everyone else throughout your Medicare journey.

Answer: Contact me and I'll help you as much as possible. It's hard to get straight answers from them.

Answer: The wisdom and knowledge. Just the stories about life. Love to help them navigate Medicare and have everlasting conversations and memories.

Answer: Yes, make sure you have applied for it because sometimes it doesn't automatically start as you would think. Once you get it start give me a call and it'll be a pleasure to serve you.

Answer: Can't be prescribed for weight loss. Has to be prescribed for diabetes unless it's a medical necessity.

Answer: Unfortunately not. Medigap plans goes up every year but it's good to shop around unless you have certain health conditions, I would advise not to.

Answer: Scope of Appointment. It outlines what will be discussed between you and the agent. Typical have to be signed 48 hours prior to the appoinment date with the agent ,unless you call them or approach them first, then the 48 hours SOA rule doesn't apply. Call centers are not exempt from them.

Answer: Yes, Medicare can cover wheelchairs if they are deemed medically necessary for home use, but approval is required, often including prior authorization for power wheelchairs. You'll need a doctor's prescription after a face-to-face examination, and your supplier must be Medicare-approved. Medicare Part B covers 80% of the cost, with you responsible for the remaining 20% coinsurance and deductible.

Answer: Options are limitless. Options are based on an individual basis. Everyone needs are different and unique.

Answer: Plans are not one fit all type plans. All plans is based on individual needs. What may work for your friend or neighbor may not be best for you.

Answer: Agents usually look all doctors to make sure they are in their network before switching plans. Make sure this is done first and no worries!

Answer: New or old, I make sure they all know the basics of Medicare and options available to them. There is alot of misleading info out in the Medicare world so I ensure they have the correct knowledge.

Answer: IF the device is medically necessary, then Medicare will cover it. Otherwise, you will have to pay for a home heart monitor out-of-pocket.

Answer: Yes, you do need to meet your Part B deductible before Medicare begins covering your physical therapy costs. Once your deductible is met, Medicare will typically cover 80% of the approved cost for outpatient physical therapy, and you will be responsible for the remaining 20%. The Part B deductible for 2025 is $257. Medicare will only cover physical therapy that is deemed medically necessary.

Answer: Majority of the plans are no cost to you. Some plans may have a premium but many will not. Always make sure that question is answered before you enroll in a plan.

Answer: To make sure you're getting every benefit that you may qualify for. Also to make a sound decision with your health needs.