Larry Dalton, Medicare Insurance Broker

Answer: The biggest mistake is listening to agents calling you from who knows where. Since I turned 65, I have received calls every week from agents claiming to be from my area and making bow statements that they can offer me something better. Another area is failing to ask about the company's premium increases, how much they go up yearly, and having documentation to back it up. Therefore, just be cautious of agents who contact you without your permission, and be cautious of what you say they may be recording.

Answer: People fail to analyze their options at the beginning of their Medicare journey, making hasty decisions or following their friends' or families' decisions. These first decisions could affect their Medicare coverage throughout their retirement years, especially their pocketbooks. You should know all the facts or have an agent that you can trust to guide you through the Medicare process when signing up for Medicare.

Answer: Yes, at any time. However, you may require medical underwriting approval. Except for the three months before your 65th birthday month, the month of your 65th birthday, three months after your 65th birthday, or 63 days after working past 65 with a company group insurance plan of 20 or more. Then there are no medical underwriting requirements within those timelines.

Answer: Under traditional Medicare, you will appeal directly to Medicare, and Medicare supplemental/Medigap coverage must follow Medicare's lead in paying your coverage cost. With Medicare Advantage, you will deal directly with the insurance companies that write those plans.

Answer: You may think that Medicare Advantage is traditional Medicare, but it is not. In fact, Medicare Advantage is private insurance group coverage that follows the Medicare guidelines. Under Advantage plans, insurance companies have the right to require prior approvals before offering coverage.

Answer: Medicare agents are not supposed to solicit customers without their permission. Therefore, it is essential that you feel comfortable with your agent and trust his knowledge and efforts to provide you with the best plan, for your future, not necessarily for the moment.

Answer: Helping others is a blessing, and it is more important to me than any commission that I received from marketing a Medicare plan. Medicare is very complex and difficult to understand until it is laid out in very precise steps.

Answer: Testing your agent and where they received their knowledge and training—understanding the two different directions a Medicare customer must choose, and knowing that it is sometimes impossible to turn back after going down that path. Why? The future of your health is unpredictable, so it is wise to plan ahead.

Answer: It depends upon your location, how much you travel, where you would like to receive coverage if the unexpected happens, and the fact that cheap is not always the best in the long run. This answer cannot be given as good or bad; everybody's circumstances are different.

Answer: Traditional Medicare and nursing home coverage provide only short-term coverage. If one needs nursing home care services in the future, it is important to get long-term care insurance.

Answer: Suppose they have a Medicare-qualified group insurance plan. In that case, they do not necessarily need to enroll in Medicare until they retire, and they then have 63 days to make that decision without penalties. However, one would need to analyze correctly what the two different coverages would consist of, the cost, co-pays, and deductibles before making the final decision.

Answer: Yes for most of us! However, if you are on a qualified Medicare group insurance plan through your employment or retired under a Medicare-recognized retirement health insurance group plan, such as a Fedblue retirement plan, there are no penalties until you leave these circumstances. Again, a trustworthy agent can explain this in detail.

Answer: Many people with very limited incomes have enjoyed the opportunity to use OTC cards to help pay for over-the-counter drugs and utilities. There is considerable debate about whether this should continue in the future and whether it should be withdrawn from the Medicare system and transferred to the Medicaid system. Medicare Advantage plans are very beneficial in many ways, but they do come with their pros and cons and should be carefully analyzed before making a decision to go down that path.

Answer: Yes, an agent should always look into areas where you may qualify for special enrollment periods (SEP), which are given throughout the year and taken away. SEP varies from state to state and from circumstance to circumstance. Again, a trustworthy agent can explain this in detail.

Answer: The agent will need to check to see what penalties will apply to your enrollment. Some of these penalties can only be determined by Medicare. But Medicare is governed by timelines, and it is very important to have an agent you trust to work out the details of your circumstances. There are 10% penalties for Medicare Part A and B in most circumstances. There is a 1% penalty for Medicare Part D on late enrollment. These penalties accumulate per month that you go without coverage, and they become part of your coverage expenses in the future under Medicare.

Answer: You can be exempt from answering health questions only during your initial enrollment (IEP)or some other Special Enrollment Period (SEP). This is why there is a saying: "You can always go from supplemental/Medigap to the Medicare Advantage plan under most circumstances, but you cannot always go the other direction." There are two paths to travel in the Medicare system.

Again, a trustworthy agent can explain this in detail.

Answer: This question cannot be answered without knowing all your circumstances, but there are just as many different answers to this question as there are agents in the field, as to why you should or should not. Again, a trustworthy agent can explain this in detail.

Answer: You are covered as long as traditional Medicare is received and you have a Medicare supplemental/Medigap. Medicare Advantage plans may vary based on your plan type, as the advantage plans are geared toward PPO and HMO networks.

Answer: Most Medicare supplemental/Medigap plans F, G, N, and a couple of others will cover 80% if Medicare is accepted. International travel medical insurance coverage plans can help cover the cost of emergency medical treatments, including broken bones, heart attacks, strokes, emergency dental procedures, and medical evacuations. Our special policies can be written for these types of events.

Answer: You will most likely need to answer health questions, but certain events, such as the anniversary or birthday, rules, or other SEP qualifying events, can exempt you from these health questions. Again, a trustworthy agent can explain these to you, state-by-state, and events.

Answer: If you qualify for Medicare Part A and B, you will be eligible for certain plans under the Medicare program and specific advantage plans based on your financial conditions.

Answer: They made a hasty decision over a telephone conversation or allowed someone to talk them into changing their coverage after utilizing their trustworthy agent to set up their long-range coverage.

Answer: I'm always available for a phone or Zoom meeting and can usually arrange to meet in person if they request it. Navigating the Medicare system takes time and should be done with someone with whom you can share confidential information about your health and finances. Again, a trustworthy agent is very important in making your Medicare decisions.

Answer: Your coverage is limited to PPO and HMO networks, and roughly 70% of major health issues will require approval before procedures can be conducted. You're required to have a primary physician who will perform and conduct your healthcare services.

Answer: AI programs are becoming very popular in the Medicare and healthcare system. We are in changing times with the Medicare system, and the future is in the hands of our leaders in Washington, DC as to outcome of our Medicare will flow.

Answer: Those that Medicare has approved for Part A and B.

Of course, there are always other insurance coverages available outside the traditional Medicare system.

Answer: I believe Medicare should have more dental, vision, hearing, and preventive care services built into the traditional system, just like many Medicare Advantage plans offer these services within their programs.

Answer: I believe that you should never push anyone into making important decisions about Medicare insurance. The decision should be made after an individual is comfortable with the answers to their questions and has done essential research on the plans to ensure proper coverage and budget, as well as meet the family's long-term goals.

Answer: I recommend starting your Medicare Part A & B, six to four months before your 65th birthday. The Medicare system is very slow and prepared for the unknown. Medicare supplement/Medigap or Medicare Advantage plans can be attained three months before your 65th birthday or retirement from a group insurance plan. You can often begin your supplement/Medigap plan before you receive your Part A and B Medicare numbers. All plans will go into effect gently on the first day of the month you turn 65.

Answer: Again, Medicare advantage works off of networks and generally the rural areas have less providers available in these networks.

Answer: That is quite all right. Medicare does not begin until you are 65 and is not part of the Social Security program. Age 65 is the most important date in the Medicare system. 62 and 70 are also important dates under the Social Security system.

Answer: Under Medicare Part A, you must first ensure that you have a doctor's order admitting you as an inpatient. This indicates that you require hospital care. Once you are admitted, Medicare Part A will cover the cost of your stay, including services like medication and testing, but it does not cover everything. That is where Medicare Part B steps in to cover the additional expenses of surgery. Of course, there will be more expenses that Medicare Part B will not cover, leaving gaps. That is when a Medigap policy comes in to cover all the remaining expenses.

Answer: Medicare supplement/Medigap plans are good for life and cannot be canceled except if you fail to pay the premium. Do your homework or work with an agent you trust. They can assure you which Medicare supplemental/Medigap insurance to choose by analyzing records of these insurance companies' rates, showing their annual premium increases. Changing Medicare supplements midstream may be impossible if you develop health issues after turning 65. However, there is a one-time birthday rule in Oklahoma that you can use to make changes without underwriting requirements. Or you could always change to a Medicare Advantage plan during the annual enrollment dates.

Answer: Medicare is trying to stop these unwanted calls. However, they still contact you even if your name is on the Do Not Call List. Most of these calls are made illegal and transferred to a contracted agent. Upon answering the phone, I was told this was what I had been told. I am 65 and have blocked over 600 numbers on my phone.

The information on the free grocery card is partially correct. It depends on your qualifications, location, plan type, or whether you are on Medicaid. These plans are available through some Medicare Advantage plans.

Answer: First, It’s essential to clearly understand the differences between Traditional Medicare with a Medigap plan vs Medicare Advantage.

Second item is the mistakenly think that starting with a low-cost plan is the best option; however, this isn’t always the case with insurance companies under the Medigap program. After the first four to five years, premiums can increase significantly, making it difficult for those with health issues to switch to a more affordable plan. Often, individuals are left at point in life with no choice but to transition to an Advantage plan a more affordable monthly rate and giving up their freedom of choice. Being informed about these options can lead to better long-term decisions regarding healthcare coverage.

Answer: You are guaranteed coverage with no underwriting evaluations starting three months before your 65th birthday month and continuing for three months after that month. I always advise people to start thinking about their Medicare coverage at least six months before they turn 65.

Answer: This question is a very vague question and difficult to answer without understanding the individual circumstances.

Medicare has tiers of cost in their Part B and part D premiums and are based on your income. This does not affect the average Medicare beneficiary unless you’re in those high-income brackets.

Insurance companies operate on different levels, and their cost structure includes high and low deductibles, that can affect your cost.

Answer: This is a significant cap established by President Biden concerning drug plans. Under typical circumstances, if your prescribed medication is included in the formulary, its cost will contribute towards the $2,000 limit. Once that cap is reached, all subsequent expenses are covered at no cost to you. This plan is particularly advantageous for individuals who rely on multiple medications or who take high-cost drugs. However, it’s essential to note that while this cap can provide substantial relief, you might discover that the premium for your drug plan is considerably higher to ensure that specific drugs are included in the formulary. Additionally, keep in mind that the premiums you pay for your drug plan do not count towards the $2,000 limit.

Answer: First, file for Medicare Part A and Part B if you’re no longer on a company group insurance plan and continue to work past 65. If you are not on a group plan past 65 that Medicare recognizes, you must file for Medicare Part D if you don’t go with the Medicare Part C Advantage plan with built-in Medicare Part D drugs. Confusing? Contact an agent, and they should be able to explain these in detail.

Answer: First, do not get into selling them on your market ideas. Be clear and precise and make sure they understand all of Medicare’s options and coverage before any decisions are made. Serving on the Medicare advisory committees has given me an understanding of how complex and confusing people can become due to misleading agents in the field.

Answer: They are different departments altogether, and many of your Medicare premiums can be held directly out of your Social Security account. I always recommend a person to set up their two accounts, one in www.ssa.gov and another one in medicare.gov.

Answer: There are various circumstances and specific conditions to consider before providing a final answer to this questionnaire. Most likely, penalties will apply if you miss your initial enrollment window for Medicare’s Parts A, B, or D. A Medicare health insurance agent can review your situation and provide you with the necessary details.

Answer: 1. A Medicare supplemental plan may be changed to another Medicare supplement plan at any time of the year.

2. A Medicare supplemental plan can be changed to a Medicare Advantage plan between October 15 and December 7. However, this change will not take effect until January 1 of the following year.

3. Medicare Advantage plans can be changed to another Medicare Advantage plan once during open enrollment, which runs from January 1 to March 31.

4. Medicare Advantage plans can revert back to traditional Medicare with a supplement plan between January 1 and March 31. However, you may be without a drug plan for the remaining of the year.

5. Medicare Part D stand long prescription drug plans can only be changed between October 15 to December 7 and do not take affect until the following year of January one.

6. There are other special enrollment periods allow for case by case situations.

Answer: In 1965, the government set up Medicare to help primary care for those over 65 with healthcare costs. President Johnson set it up to share healthcare costs between the government and beneficiaries. This was called the cost-sharing approach, with the intent to help control Medicare abuse and overcharge by discouraging unnecessary use of the services.

Today, with healthcare costs rising, the original design has revealed six major gaps in its coverage. Therefore, yes, I think it was designed this way in the beginning, which makes it very confusing today. You need to make sure you have the right coverage and can’t afford the coverage of these gaps.

Answer: IRMAA's income tables for singles and married couples filing jointly are pretty cut and dry. They are designed to share these expenses with individuals whose incomes exceed those of regular Medicare patients. In a professional opinion from an agent, the agent can only explain how these tables are set up, but the individual’s CPR or tax attorney can lay out alternative options.

Answer: Medicare Part A is free to us if you meet the number of paid-in working units required by the Medicare statutes, over the course of your career. Suppose you are under a Medicare-qualified employee group plan at turning 65. In that case, you do not need to take out anything else, and all penalties will be waived until you leave the employee group plan sometime in the future. The Medicare Part A insurance will be utilized with your group insurance for your claims. However, if the Medicare employee group plan does not include prescription drugs, taking on a Medicare Part D prescription drug plan may be necessary to avoid penalties. Your plan needs to be evaluated by a licensed Medicare insurance agent that you trust to ensure the accuracy of your decision.

Answer: Yes, this is your savings. However, HSA savings come from a financial account made available through employment. Many of the contributions to this fund are made without paying any taxes on them. Therefore, withdrawing this money from your HSA to reimburse yourself for Medicare premiums, etc., could be subject to taxes if they are not appropriately used for medical expenses.

Answer: Suppose you're under Medicare Part A and Part B with a Medicare supplemental insurance, and the physician sees a need for a diagnosis due to your health circumstances. In that case, the procedure should be covered, less any amounts for Medicare Part B premium or deductibles, and this is based on the type of supplemental plan you have. If you're on Medicare Part A and B with a Medicare Part C - Advantage plan, then your coverage could only be determined with the prior approval procedure through the insurance carrier of your Advantage plan. Most likely, there will be additional deductibles, co-pays, or out-of-network charges under these plans.

Answer: Medigap gives you total independence to go wherever they accept Medicare without worrying about any additional unforeseen charges, and this does come with the upfront price, but it gives many people peace of mind. This is often referred to as "pay upfront and forget about it, or pay as you go." It is important to note that a good agent will evaluate the carrier's past history and can give you a report of the premium increases they have had, often they have had them, and the rate within the health industry that they carry. This is important when you first begin your insurance coverage.

Answer: You can always convert your Medicare Insurance plan from the traditional or original Medicare coverage with a supplemental plan to a Medicare Advantage plan "at any time" throughout your life, regardless of your health conditions.

However, converting back from a Medicare Advantage plan to the original Medicare A & B with a Medicare supplemental plan could present a significant problem. Why? After passing up the special exemptions period (known to some as the Golden Opportunity), with Medicare supplement plans, then the insurance companies have the right to evaluate your healthcare conditions before accepting you into one of their Medicare supplemental or Medigap plans. Health examinations or health questions are not utilized to determine the approval of a Medicare Advantage plan.

Answer: The extra add-ons to the Medicare advantage plans, such as dental, hearing, and vision coverage, are one area to be sure to evaluate each and every year, as these plans change annually and must be renewed annually. Another area is those who receive cash cards to help cover OTC utilities, etc., which are subject to change from year to year and are being carefully analyzed in Congress today as to whether to continue allowing such benefits.

Answer: Medicare Part D drug tiers are the drug manufacturers' way of controlling costs. It is extremely important to make sure that your drugs are in the formulary, and these tier structures change annually. All Medicare Part D stand-alone drug plans and the Part D drug plans embedded in the Medicare Advantage plans must be analyzed yearly to ensure that you have the proper plan to cover your prescription drugs. Many drug plans utilize the tier structure to determine whether to allow the drug to be used towards the annual deductibles of that drug plan; this should be paid special attention to when selecting a drug plan.

Answer: As the cost of medical care increases with inflation, so will the cost of medical insurance premiums, deductibles, coinsurance, and co-pays. Whether it will ever become unsustainable is a question that only time can honestly answer. What is the future of America's healthcare costs?

Answer: Under traditional Medicare Part A and B with a Medigap plan, Medicare generally does not cover pre-symptomatic genetic testing for cancer risk assessment. However, with a doctor's order for the testing, it will most likely be approved for certain types of cancer testing. Some Medigap plans come with a rider that covers 100 percent of preventive care testing.

Under the Medicare Advantage plan, these tests most likely will require prior approval from the insurance company.

Answer: Yes, under traditional Medicare A & B with a Medigap plan, Medicare will cover some home health services after surgery. Under Medicare Advantage plans, this will require prior approval by the insurance companies that carry the plan.

Answer: No. To be eligible as a green card holder, you must live in the United States for five years before applying for Medicare.

Answer: Yes, under Medicare A & B, you may find that Medicare will cover your screening potentially every two years, under a doctor's order. Preventive care testing is offered as a separate rider with your Medigap programs, with some insurance carriers. These additional rider programs generally cover one hundred percent of the cost if classified as preventive care screening.

Answer: Medicare agents can solicit customers through marketing advertisements and mail, but cannot make unwanted phone calls if you are on the do-not-call list. These calls are not legal! The marketing of Medicare Advantage plans is often very aggressive, and it is recommended that you do not act in haste when dealing with these plans. Medicare Advantage plans can be a very accessible and rewarding substitute for traditional Medicare with a Medigap plan. However, these plans must be carefully considered in conjunction with your in-network physicians and other healthcare providers you may be using in your area.

Answer: There are two categories to consider: the U.S. spends an average of $12,000 per person, per year on those under Medicare A & B with a Medigap plan. This amount is less than the payout for Medicare Advantage customers in 2023.

In 2023, the U.S. spent a total of $839 billion, and is projected to increase to over 1.6 trillion by 2023.

Answer: Medicare Advantage plans can be beneficial, but they come with certain limitations. These plans restrict your healthcare providers or services under the PPO (Preferred Provider Organization) and HMO (Health Maintenance Organization) networks. You often need preapproval for about 70% of procedures under a Medicare Advantage plan. You must have a preferred Physician as your primary physician, and a referral from your primary care physician is required to see other specialists in or outside your network.

It's important to note that these plans are often designed with specific geographic areas in mind, which may limit your access to available providers outside of your local area. However, Medicare Advantage plans offer many additional services that traditional Medicare with Medigap plans may not provide, and they cover your prescription drug plans with zero to low monthly premiums. Medicare Advantage plans are only good for one year and must be renewed yearly.

Answer: Traditional Medicare Parts A and B with a Medigap generally do not cover Hearing Aids. However, you could get a rider to add to your Medigap that offers that coverage. Medicare Advantage plans do offer some help with Hearing Aids through discounts.

Answer: With your Medigap Plan F, there should not be any cost for an emergency room visit unless you are traveling outside of the U.S. Plan F will then cover 80% of most of your medical expenses for international travel, provided they accept Medicare. If not, you may need to file it with your insurance when you return to the States to recover your cost. There is a lifetime maximum on international travel expenses.

Answer: Medicare does cover cataract surgery, and I have personally undergone the procedure. However, they only cover standard lenses, and you will need to pay extra if you want to purchase a premium lens or any other special types. These are considered luxury items or cosmetic options by Medicare and are not deemed absolutely necessary. Nonetheless, Medicare does cover the cost of the surgery as well as the standard lenses.

Answer: If you have traditional Medicare and a Medicare supplement plan, also known as Medigap, then you are covered. However, if you are on a Medicare Advantage plan, you need to ensure that your healthcare providers are in your plan's network.

Answer: Yes, but it is covered under Medicare with a doctor's order. This test is generally covered only once every 24 months.

Answer: When it comes to Medicare, with Medicare Part A and B and the additional purchase of a Medicare supplement, or some call it Medigap, you can receive several preventive screenings and services at no cost. Diabetes, colon cancer, depression, hepatitis B, hepatitis C, HIV, cholesterol, and mammograms can all be covered without cost, if you have a Medicare supplement plan added to your traditional Medicare Part A and B.

Answer: Yes, if your physician deems it medically necessary. However, some other EKG devices are most likely not covered by Medicare.

Answer: This is a difficult decision in a person's life when they're making their care decisions for someone else. To legally manage your elder parent, you'll need to see an attorney or get the attorney's advice on whether to use a power of attorney or have the court appoint you as a guardian. There are some other online procedures that you could use to obtain legal authority to manage Medicare.

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Answer: This is a considerable debate among Medicare beneficiaries and our government. The possibility of prioritizing Medicare is happening through the Medicare Part C Advantage plans, known as managed care under the supervision of major insurance companies. However, it is in the individual's choice to choose which direction they're going with Medicare. As Medicare Advantage plans continue to improve their services and networks of managed care, we will see more and more individuals moving in that direction.

Suppose traditional Medicare Part A and Part B, with a Medigap plan, offered similar services like dental, hearing, and vision coverage to Medicare Part C advantage plans. In that case, they may not be as attractive. Traditional Medicare does not have in-network services, so you can use your benefits anywhere that they will take Medicare.

Answer: Medicare savings programs, known as MSPs, can qualify you for extra services and benefits. These services may help reduce Medicare Part A and Part B premiums, deductibles, and coinsurance payments and assist with Medicare Part D drug plans.

Answer: This is in relation to the penalties for failing to sign up within the time frames for Medicare Part B or Part D. Missing these dates can significantly cost seniors throughout their remaining lives. It can also affect the choices that you may make on your Medicare Advantage plans. Check with your agent about the timelines and penalties for missing out on signing up.

Answer: Medicare covers specific genetic tests if they are medically necessary and meet particular criteria. The cost of these procedures will be handled through expected Medicare benefits in payment. However, specialized clinics and procedures should always be verified for Medicare coverage before using them, and the medical necessity of such procedures must be demonstrated.

Answer: An HMO limits your services to a closed network of physicians and caregivers. HMOs require members to choose one of their in-network primary care physicians to manage your healthcare, and require a referral approval to use other in-network services. HMOs generally do not allow any out-of-network services unless it's an emergency.

PPOs are more flexible with their network of services and do not necessarily require a primary caregiver. You can use services outside of their network of treatment services, and you will still be covered. However, PPOs generally have higher prices, deductibles, copays, and coinsurance when you use services outside of their network.

Answer: This year of 2025 there are no known holes in the prescription drug plans. All drug plans are mandatory with this feeling of $2000 out-of-pocket expenses for the beneficiary. However, it is important to make sure that your drug plan includes your prescription drugs in their formulary so that you get full benefit of the out-of-pocket expenses.

All part D prescription drug plans should be reviewed annually

Answer: Concierge Care will work with Medicare, but doctors may still charge you for some items that Medicare will not cover but may be covered under Concierge Care. Concierge services are not reimbursed by Medicare.

This is good for having an extra layer of coverage. The premium for this coverage is not covered under Medicare, so this is one way to get extra insurance coverage and your Medicare. Medicare Advantage networks also work with Concierge.

Medicare does not reimburse concierge services, which provide this enhanced care.

Answer: With my experience in Medicare, including serving on some of their advisory committees, I observe that Medicare Advantage programs continue to grow and become more aligned with traditional Medicare regarding coverage and transparency. These programs, which are based on insurance companies' network systems, are still somewhat different from traditional Medicare. Traditional Medicare operates on a fee-for-service model with no networks or the need for prior approval for Services. Medicare Advantage programs have not yet fully reached that level of services with their networks. However, medicare advantage programs offer some additional services that traditional Medicare does not do through Part A and Part B. Medicare is actively working to improve these programs and services as part of its commitment to enhancing the Medicare system.

Answer: Yes, Medicare is increasingly covering AI diagnostic tools and services. AI is becoming a major player in all aspects of our lives and continues to grow in knowledge every day. It is being used to help diagnose people’s healthcare problems. However, it’s in its early stage and still needs to have the oversight of humans' approval before it can be accepted as a proper diagnosis.

Answer: In 2025, all Medicare Part D plans have a $2,000 annual out-of-pocket maximum for covered drugs. Medicare has set up a payment plan to help offset the burden of paying for this $2000 cap. Once you reach this limit, your plan will pay 100% for your covered medications for the rest of the year. However, you must still pay your portion of the out-of-pocket costs upfront at the pharmacy or through the payment plan. This cost depends upon the drug's tier and the drug plan’s deductible, which is based upon the different drug plans available.

This cost can be easily disbursed through the Medicare payment plan, lowering your monthly drug cost. It does not change that you must pay for upfront or throughout the coming months with the Medicare payment plan.

Your monthly drug cost with this Medicare payment plan is based on what you would have paid out of pocket at the pharmacy for your prescriptions that month, plus your previous month’s balance. It is divided by the number of months left in the year.

In other words, if your out-of-pocket drug cost is $1200 a year, then you would be paying $100 per month. This does not include your premium for the drug plan.

Answer: No! Medicare does not consider items like these to be medically necessary. Having worked in the medical Durable Medical Equipment (DME) industry for many years, I understand that it can be extremely challenging to obtain insurance coverage for these products. However, in Oklahoma, if you have a medical prescription that states a diagnosis justifying the need for this device, you can purchase it without paying sales tax, provided it is used in your home.

Answer: This process is known as the coordination of benefits in medical billing. Your primary insurance pays first, and then your secondary insurance, such as Medicare, covers the remaining eligible costs. I have found that Veterans Affairs (VA) benefits often do not work well with outside their contractors and frequently do not cooperate with the outside billing process.

The VA has its own private contractors and billing procedures that they prefer to use. As a result, you will often find that each provider handles its own coverage separately.

Answer: Moving to a new state or outside your coverage area can trigger a Special Enrollment Period (SEP) for Medicare Advantage and/or Part D plans. This allows you to find new coverage in your new residential area. Whenever you move, it's important to notify Medicare of your new address. Depending on your location, you may be subject to different rates and reimbursement options.

However, your Medicare Part A and Part B coverage remains unchanged across all states. This only affects the portion of the Medicare system that is handled through insurance companies, such as your Medigap plans, Medicare Advantage plans, and Part D plans.

Answer: In my opinion, any time you deal with an insurance plan, you could be surprised by the billing procedures. Medicare Advantage plans are underwritten by insurance companies, and they offer special incentives to help offset the inconvenience of using these plans.

There should be no surprises when dealing with Medicare Part A and B. Medigap is mandated to follow the Medigap plan of your choice (A through N plans), and cannot deviate from these requirements. However, Medigap plans require underwriting approval after the period that grants you the right to purchase such plans without any underwriting requirements.

Answer: The Social Security Administration office will notify you if IRMAA will apply to you, for it is calculated annually upon your tax returns. These rates may change yearly by Medicare and are publicized in your annual Medicare booklet. The amount you pay changes yearly and is recalculated from the income you submit on your tax return for that year.

Answer: Yes, insurance companies could deny coverage. However, you can request an appeal if the drug is medically necessary. You will need your physician's support and documentation of the need. The insurance company may agree to a designated amount for the drug, but it may not be in the formula or on any tier levels.

Answer: Traditional Medicare with a Medigap plan does not typically cover smartwatches, as Medicare standards have not approved them as medical devices under durable medical equipment (DME) monitoring devices. This is similar to a blood pressure kit that Medicare does not see as a medical necessity under DME monitoring devices. A Medicare Advantage plan may pay for the smartwatch, but it would require prior approval.

Answer: The best time to enroll in Medicare is during your Initial Enrollment Period (IEP), around your 65th birthday, or when you are coming off a Medicare-approved company group Insurance plan. After this period has elapsed, the next best time will depend upon your circumstances. For most of us already on Medicare, it would be between October 15 and December 7 of each year.

Answer: Traditional Medicare with Parts A and B and a Medigap plan F or G, could cover up to 80% where Medicare is accepted. Medicare Advantage plans would need prior approval from the insurance company that is carrying the plan.

Answer: Medicare comes in different parts (A, B, C, and D), and your choices determine your cost. Choosing a cheap or simple plan during your initial enrollment could jeopardize your ability to choose other plans later in life that could benefit you the most regarding health coverage.

An independent health insurance agent should be able to show you the difference in these areas. If you choose this cheaper plan today, ask your agent lots of questions about your long-term goals, coverage, and premium costs five, ten, or fifteen years from now.

Answer: I’ve always stated that you should plan with good health coverage, but budget for today. It is difficult to project the future outcome of your health, but getting the right coverage in Medicare today can help alleviate expensive costs in coverage for tomorrow.

Answer: With the changes made in 2025 to the drug formulas and tears, it is wise to analyze all the plans. Cheaper premiums could cost you more in the long run at the pharmacy. I would always investigate the drug plans each year.

Answer: This is a long-time debate. Some feel we need to privatize Medicare, and others feel we need to let the government control it under a one-plan-for-all. Health decisions are very private, and with that being said, many areas in the Medicare system need to be adjusted or approved, along with the idea of using newer technology.

Answer: Approving a medication by Medicare is always based upon the justification of the medical necessity of that drug. The insurance company that underwrites the medical prescription drug plans lays out their drug plans each year to determine what will be covered under what plan. This is the time when you sit down with your Agent and review every drug plan for your ZIP Code with your prescription drugs. This is the best answer I can give you for now without knowing which drug plan you choose, and usually, there can be justification given for a weight loss drug being required.

Answer: Yes, under Original Medicare Part A, you are eligible for hospice benefits if a doctor certifies that you are terminal illness. These benefits cover your cost, even if you are enrolled in a Medicare Advantage plan. However, you will still need Medicare Part B and pay the monthly premiums. Depending on your Medigap plan or Medicare Advantage coverage, you may have some out-of-pocket expenses.

Answer: The United States formed Medicare in 1965 to help seniors with their healthcare. Medicare and life insurance serve two different purposes. Medicare doesn’t replace life insurance, or offer death benefits, or cover expenses after death.

However, Medicare will pay a lump sum of $255 to help with your barrel arrangements.

Answer: There should be little to no difference in coverage between traditional Medicare Part A and B and with a Medigap plan. Of course, some states require a few extra details in the Medigap plans, such as prevented care items.

Medicare Advantage plans differ in some ways in providing requirements and services within and between states. These decisions are not Medicare decisions. They are based on the insurance carriers that provide these Advantage plans and the individual state regulations.

Answer: When turning 65, Medicare Part A is automatically given to you at no cost. You should not need to do anything, but I would always double-check if you haven’t received your card before you turn 65. Medicare Part B, you sign up for yourself, and if you do not, you’ll be penalized for the rest of your life for every month you go without signing up. Medicare Part D also requires that you sign up when you turn 65, or you’ll be paralyzed for each month that you go without it for the rest of your life. An agent can help you complete these tasks. Having Social Security before turning 65 does not exempt you from these items. You’re still required, and Medicare is separate from Social Security.

Answer: Medicare and Social Security are two different government accounts and departments. Medicare is funded by Congress each year out of the same bucket from which our federal military receives its money.

On the other hand, our Social Security accounts are sovereign from other Government activities. That means that what goes into the Social Security account is only paid out to Social Security benefits.

The Social Security account is fully funded until around 2035, and after that, Congress will have to subsidize Social Security payments. It has been stated that after 2035, not enough money is being paid into the Social Security account as Social Security is paid out.

Answer: This situation can be incredibly challenging, and I can relate deeply as I've experienced similar moments with both of my parents. It's so important to approach them with kindness, avoiding any demands or pressure, as accepting their current reality can often be difficult. Listening attentively to what they’re feeling and saying is crucial, and sometimes having someone outside the family that they trust can make a significant difference in how they express their thoughts in this conversation.

At this stage of life it’s vital to protect both their health and their assets. Understanding Medicare can be quite confusing, especially with the complexities created by the government and unfortunately, by some individuals who take advantage of the system.

These decisions could take time and come with its share of anxiety, so it's essential to prepare yourself when discussing your parents' insurance coverage. Try to get them to look at Medicare with a mindset that focuses on providing them and their love ones the ensure that their health coverage will be met for their remaining years. Remember, compassion and support will mean the world to them during this time.

Answer: IHS, Indian Health Services, is not health insurance, and it is only available at tribal clinics throughout their nations. Working with many Native Americans in Oklahoma, I have seen that having Medicare alongside the IHS can help provide healthcare providers and specialists outside their IHS clinics and hospitals. Some may find that having this dual coverage will give them the best Healthcare anywhere in the USA.

Answer: While many Advantage plans vary between networks and carriers, it's important to note that some can offer substantial coverage, and I’ve seen some reaching up to $1,700 per year for dental services. The type of coverage depends on whether it’s root canals or plain fillings, and that needs to be considered. However, it's essential to recognize that these plans may not be as comprehensive as standalone dental plans. Verify that your dental clinic is within the plan’s PPO or HMO network to maximize your benefits. This ensures you receive maximum benefits.

Answer: Dental, hearing, and vision coverage is not included in traditional Medicare. You must purchase a standalong policy or maybe a rider to obtain these benefits.

However, Medicare Advantage programs, which are offered by insurance carriers, often include these benefits in their plans. It's important to note, though, that the coverage provided by Medicare Advantage plans is generally not as comprehensive as standalone dental policies, and hearing, and vision coverage, but they do offer the basics and some of them do go a little deeper in their benefits.

Answer: It's important to understand that Medicare Advantage is not the same as traditional Medicare. Medicare Advantage is a type of group insurance plan created by an insurance company that adheres to Medicare guidelines to serve beneficiaries. Although some Medicare Advantage plans may have a zero monthly premium, they often come with various other cost factors that can arise when using the coverage. Here are some key points to consider when switching to a Medicare Advantage plan:

1. Some individuals may encounter difficulties when trying to switch back to traditional Medicare after enrolling in a Medicare Advantage plan, particularly due to their health conditions.

2. Medicare Advantage plans operate within provider networks, such as PPO and HMO networks.

3. Approximately 50 to 70% of surgeries or other therapies may require prior approval.

4. Coverage is subject to specific geographic areas, and you may need to obtain approval for services outside those areas.

5. Under Medicare Advantage, your out-of-pocket costs for one year of service could be significantly higher than with traditional Medicare combined with Medigap, especially if you have serious health conditions.

6. Medicare Advantage programs must be renewed each year, and the plans are subject to change annually.

Answer: Yes. Medicare supplement plans are often referred to as Medigap plans. These plans work in conjunction with your traditional Medicare, but do not take the place of traditional Medicare, as Medicare Advantage plans do.

Answer: You may wonder whether Medicare benefits are portable when traveling. Traditional Medicare Part A and Part B coverage is portable within the borders of the USA, Puerto Rico, the U.S. Virgin Islands, Guam, American Samoa, and the Northern Mariana Islands. With traditional Medicare and a Medigap plan, you are covered with no network restrictions and can see any provider that accepts Medicare.

Traveling with Medicare Advantage. These plans are not the traditional Medicare, and insurance carriers underwrite them entirely. Therefore, signing up under these carriers is not straightforward due to their network, which may not be available outside your state or within their standard geographic areas. Some Medicare Advantage plans have state-to-state and nationwide pharmacy coverage within their extensive networks. However, other Medicare Advantage plans may not cover outside their defined service area or impose higher cost-sharing or prior-authorization rules for out-of-network care. When traveling, remember that if your Medicare Advantage plan requires a primary care provider (PCP) referral for specialist visits, you must do your homework; otherwise, you may have trouble finding a specialist when needed.

However, rest assured that original Medicare and Medicare Advantage plans are required to cover emergency and urgent care anywhere in the United States without additional restrictions or out-of-pocket costs.

Answer: They do not understand the Medicare Advantage MOOP limits, which the federal government has set at $9,350 for Medicare Advantage plans in 2025. You may be expected to pay this maximum out-of-pocket cost annually for the covered services. But some carriers allow you to choose or set lower limits on possible out-of-pocket expenses.

Under traditional Medicare, with a Medigap plan, the out-of-pocket expenses are determined by the type of Medigap plan you choose. The drawback with these types of plans is that the insurance carriers underwrite these Medigap plans and have the right to increase monthly premiums. However, they do not have the right to pick or choose or in any way limit your services, and must pay according to your Medigap plan wherever traditional Medicare is accepted.

Answer: Guaranteed issues for Medicare supplement plans ensure you can purchase a Medicare supplement/Medigap plan that picks up the gaps that Medicare Part A and B leave behind. A guaranteed issue means you do not have to be questioned about your health conditions with the insurance underwriters, and the policy will not be denied. Guaranteed issue applies to the six months around your 65th birthday. Three months before your 65th birthday, the month of your 65th birthday, and three months after your 65th birthday, you have the right to get a guaranteed issue policy for your Medigap plans. After that, there are some special guarantee issues when retiring from a group insurance plan, but that would be for another discussion.

Answer: There is assistance to help those with difficulty meeting their financial needs. I advise seeking extra help through the Low-Income Subsidy (LIS) and Medicare Savings programs. Although these programs may not cover one hundred percent of your drug costs, they can help offset expenses. You can also check with the State Pharmaceutical Assistance Program, known as SPAP, in Oklahoma or Texas, which offers additional help with drug costs. To sign up for your LIS, low-income subsidy program, I recommend seeking assistance at the Department of Human Services, which manages the state Medicaid programs. You can also apply through the Social Security Administration. If you are on Medicaid or SSI when you sign up for Medicare, you will automatically be enrolled in this Medicare Savings Program.

Answer: A Medicare Summary Notice (MSN) is sent after a healthcare provider files a claim with Medicare for services. The MSN summarizes the claim details, including what was billed and paid to the provider. The Medicare-approved amount is how much Medicare paid on the charges, and what’s left over is your obligation if you don’t have another secondary insurance to pick up those charges. You should always review your MSN to ensure the information is accurate and to track your out-of-pocket expenses.

Answer: Medicare does not provide annual physicals; these are called wellness exams. If the doctor bills it as a physical, you will most likely pay 100%. However, if you have a Medicare Advantage plan, it may be covered as an annual physical under your policy coverage. All Medicare Advantage plans are different, and their coverage for these items varies; check your policy.

Under traditional Medicare Part A and B, you can receive a yearly wellness exam. Talk to your doctor about the upcoming exam and what it entails.

Answer: When leaving a Medicare-recognized group plan at retirement, you have some of the same opportunities that you had when you turned 65. Most only have Medicare Part A, and some may carry Part A & B. However, the day you retire, and you are over 65, your time clock begins regarding upcoming penalties for failing to enroll. First, you have eight months to enroll in Medicare Part B to avoid penalties. However, you have only 63 days to sign up for a Medicare Part D prescription drug plan, or a guaranteed issue right for certain carriers on Medigap plans, with no pre-existing evaluation, and 63 days for a Medicare Part C Advantage plan. But you can't sign up for any of these plans until you sign up for Medicare Part B. Therefore, you should sign up immediately for Medicare Part B or the month before retirement, before your current coverage ends, to help you avoid a coverage gap. Now, with the retirement date, you have two choices: to go with Medicare Advantage coverage or a Medigap plan. This decision will determine how you go with Medicare Part D. Remember, this is for employees who stay on a company group health insurance plan of 20 or more employees past age 65.

Answer: All insurance agents who sell Medicare plans must be licensed in the state where you live and registered with that state. These agents are assigned a National Producer Number (NPN) by the state of their residence, which indicates their licensing status. Insurance commissions in all states can verify that the agent is a licensed professional authorized to provide you with any insurance policy. They must be registered with each state.

Answer: Yes, you can switch from a Medicare Advantage plan to Original Medicare, but this could require you to enroll back under a Special Enrollment Period (SEP). However, switching back to traditional Medicare Part A and Part B is available but may cause additional circumstances. Your Medicare Advantage generally comes with prescription drug plans. Therefore, you may need to add a stand-alone Part D prescription drug plan at that point, and the enrollment in these plans has special enrollment periods. You could find yourself without drug coverage in the middle of the year, and subject to penalties for not having a proper drug plan for the remainder of that year.

Answer: Palliative care can begin at any point in the patient's care, whereas hospice services are for patients with a life expectancy of six months or less or who are no longer seeking treatment. Medicare Parts A and B cover most outpatient Palliative (hospice) care services, whereas Medicare Advantage plans could be determined by the carrier and type of plan you select.

Answer: Marijuana or marijuana treatments are not recognized by federal law, even though states may recognize it as a form of treatment. Since federal laws govern Medicare, it does not acknowledge marijuana as a legal treatment, regardless of whether it is legal in your state for medical purposes.

Answer: As a licensed agent, I have not personally encountered an appeal process with a client. However, having worked in the medical healthcare field for 40 years, I have navigated numerous challenging situations and have advocated for my clients' best interests. I am pleased to share that I have successfully resolved over 60% of these appeals. The billing process can be complex, and I always recommend involving someone with my expertise and your healthcare provider when facing these types of challenges. The more expertise you have involved in the battle pulling for you, the more likely you are to win.

Answer: Medicare Part B allows for this type of coverage, including group and individual therapy. However, there may be small co-pays or deductibles that you will need to meet. Your Medigap plan can also help reduce your out-of-pocket expenses with traditional Medicare. If you choose a Medicare Advantage plan to assist with these expenses, then yes, Medicare Advantage plans must provide the same coverage as your traditional Medicare Part A and B services; however, it may require prior approval, and you may be required to pay co-pays and coinsurance costs.

Answer: This is called long-term care services. Medicare does not typically cover long-term care expenses associated with retirement communities. However, Medicare Part A & B covers medically necessary services such as physician visits, hospitalization, and some DME services, which depend upon the type of facility and how it is classified by the state.

Answer: Yes, when medically necessary and prescribed by your physician, there are no limits on the number of visits. You will be expected to pick up 20% of the charges without a Medicare supplement or Medigap plan. Medicare Advantage plans will do likewise, and in some cases, they may offer additional benefits, but most likely, there will be extra cost-sharing involved in the treatments. Some Medicare Advantage plans may require prior approval before treatments.

Answer: A difficult decision is involved here, where Medicare generally does not cover long-term custodial care. However, if you're fortunate enough to have a long-term care insurance plan, it would play a major role in covering these expenses. Your Medicare may cover some medically necessary Hospice care in these facilities, and another alternative is to explore your state for potential state and federal programs that could help cover your costs.

Answer: The medicare part B premium can be reduced in a few ways.

If you’re on a Medicare supplemental plan, you can always move to another one if you pass the health issue questions. All Medicare supplemental plans are identical if you’re discussing a Plan G with one company or another. The premiums are the only changes between companies with the same Plan.

If you’re on a Medicare Advantage plan, you may qualify for low-income help in several areas. This will depend up on the state you live in and your ZIP Code. A trustworthy agent can help you locate the best possible plan to meet your financial needs.

Answer: Choosing between traditional Medicare with a supplemental plan and a Medicare Advantage plan involves careful consideration of your specific needs and priorities, particularly regarding dental coverage.

Traditional Medicare, along with a supplemental plan, offers the advantage of immediate coverage at any provider that accepts Medicare, providing peace of mind with no unexpected costs. On the other hand, opting for a Medicare Advantage plan means transitioning to a private insurance group that may offer additional options, including dental coverage.

However, it’s important to note that with these plans, you may have access to a more limited network through PPO and HMO options, and pre-approval for certain services might be required. Ultimately, the decision comes down to balancing your desired coverage with your plans for future travel or any specialized care needs outside of your local area.

Answer: Although Medicare Part A primarily covers hospital insurance, it mainly focuses on room and board and other additional hospital services.

However, it does not include the medical care received under Medicare Part B. Medicare Part B covers expenses such as anesthesiologists, surgeons, physicians, and other services during a hospital stay. However, there are still gaps in your coverage that Medicare Part A and B do not cover 100%. These gaps can be filled by a Medicare supplemental plan, often referred to in the industry as Medigap plans, which helps cover the remaining balance of the costs.

There is also a penalty if you do not take your Medicare Part B out when it is offered to you. This penalty is for each month you go without Part B, and it is carried throughout your lifetime.

Answer: Yes, due to health conditions, you can be denied a Medicare supplement (Medigap plan). However, during your initial enrollment in Medicare you have guarantee right. You have three months before your 65th birthday, the month of your 65th birthday, and three months after your 65th birthday, that no insurance company can deny you supplemental (Medigap) coverage.

If you continue to work for a company past 65, and remain on their group insurance plan, then decide to retire, you have a guaranteed issue when you come off the company group health insurance for the next 63 days.

There is also a Medigap Trial Rights available. When you first join Medicare and choose to use a Medicare Advantage plan but decide later that it is not the right choice, you have one year to switch back to the Medigap plan with guaranteed coverage.

In some cases, if your insurance carrier goes bankrupt or a policy has been terminated, you could be given a guarantee issue on a Medigap plan. However, it is important to note that not all insurance companies or states are required to meet these guarantee issues except on the initial enrollment or by a government mandate.