Larry Dalton, Medicare Insurance Broker

About Me

Hi, I’m Larry Dalton, your local Medicare insurance agent. Medicare is my specialty, and I am dedicated to helping you find the best plan that fits your specific needs and budget. I will search through options from both nationally and locally recognized companies, so you don’t have to. Best of all, my services are entirely free to you.

With 40 years of experience working with Medicare, Medicaid, and private health insurance, I bring valuable knowledge. I served as President of the Oklahoma Medical Equipment Providers Association (OMEPA) for nine years. I have worked collaboratively with state and federal legislators, including U.S. Senators and Representatives, and the Oklahoma Medicaid committees. I've represented Oklahoma’s healthcare interests at the state and national levels. For the past five years, I've served on the national Medicare Advisory Council boards and hope to identify and address issues affecting the Medicare system nationwide.

At 65, I navigated the complexities of Medicare and experienced the confusion surrounding its various parts (A, B, C, and D) and related regulations. This experience inspired my commitment to helping others understand their healthcare options, including cost structures, services, copayments, and plan networks.

I am the owner of D&D Ins. Group, LLC, a licensed health insurance broker and Medicare educator, operates in Oklahoma and Texas, serving Medicare-eligible individuals. My mission is to help people find the best healthcare coverage that ensures they have low to no premiums throughout their retirement years. I am available for appointments at Medical Center Pharmacy, located at 1026 Radio Rd, Durant, OK. However, I can also make alternative arrangements by phone or at your residence. I am committed to providing you with resources, even if I don't carry that coverage. It's all about you, not me or the sale. Don’t hesitate to contact me today to explore your Medicare insurance options.

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I acknowledge that a licensed insurance agent may contact me by phone, email, or mail, to discuss Medicare health plan options, including Medicare Advantage, Medicare Part D and Medicare Supplement plans. I accept the terms of service and privacy policy. This is a solicitation for insurance. Your information will ONLY be sent to Larry Dalton. No other insurance agents or agencies will receive this inquiry.

Not affiliated with the U.S. government or federal Medicare program. "We do not offer every plan available in your area. Currently, we represent organizations that offer many products in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on your options."

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Q&A with Larry Dalton

What is the biggest mistake seniors make when enrolling in Medicare?

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.

If you had to pick just one, what's the worst Medicare-related decision someone can make?

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.

Can I change my Supplemental/Medigap plan at any time?

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.

How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?

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.

What is one of the the most common misconceptions people have about Medicare?

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.

What benefits are there to working with a Medicare Agent near me vs remote/virtual?

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.

What do you enjoy most about working with Medicare clients?

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.

What's one piece of advice you wish every senior knew before picking a Medicare plan?

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.

Is Original Medicare or Medicare Advantage better? Why do you recommend one over the other?

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.

Does Medicare fully cover nursing home care, and are there alternatives?

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.

If a senior is turning 65 but still working, should they enroll in Medicare or delay it?

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.

Will I be penalized if I do not enroll in Medicare when I turn 65?

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.

What shift has been observed in Medicare spending, particularly regarding Medicare Advantage plans?

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.

Am I eligible for a Special Enrollment Period if I lose employer coverage?

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.

What do I need to do if I didn't take Medicare at 65 and am now retiring?

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.

Can I switch from a Medicare Advantage plan to a Supplemental/Medigap plan during the Annual Enrollment Period without answering health questions?

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.

How do I know if a Medigap policy is right for me, and what's the best time to buy one?

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.

Does Medicare cover health care services on a cruise ship?

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.

What additional coverage options are available for international travelers?

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.

Do I have to answer health questions when switching from one Supplemental/Medigap plan to another?

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.

What's the process for signing up for Medicare if I'm already on disability benefits?

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.

What's one Medicare decision that too many people regret later?

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.

Can you describe a time when you helped a client navigate a complex Medicare issue?

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.

What is the biggest disadvantage of Medicare Advantage?

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.

What role do you think technology will play in the future of Medicare?

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.

Who qualifies for Medicare coverage if they are under 65?

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.

Should Medicare cover dental, vision, and hearing, or would that just make it more expensive for everyone?

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.

What are some ways to ensure your parents feel supported during the Medicare decision-making process?

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.

I'm retiring next year - do I need to do anything with my Medicare?

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.

If I move to a rural area, how might that limit my Medicare Advantage plan options?

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

What happens if I am already retired and collecting Social Security when I turn 65?

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.

I just got Medicare Part A, and I'm worried about hospital stays. How do I know if my overnight stay will be covered fully?

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.

What are the signs that it's time for me to switch my Medicare plan, and how often should I review my options?

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.

I got a call from a "Medicare agent" promising me free groceries and I almost fell for it. Why is this kind of marketing allowed?

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.

What's the most frustrating misconception you have to clear up with clients about Medicare every year?

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.

I'm turning 65 soon, when can I enroll in Medicare?

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.

Could Medicare ever adopt a tiered premium system based on lifestyle factors?

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.

Why is the new $2,000 out-of-pocket maximum for drug costs important?

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.

I'm turning 65 next month; what are the first steps I should take regarding Medicare enrollment?

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.

How do you educate clients who are completely new to Medicare?

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.

How do Social Security and Medicare work together for people with disabilities?

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.

What if I missed my window to sign up?

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.

I'm confused about when I can change my Medicare plan. Can you clarify the different enrollment periods for me?

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.

Why does Medicare have so many coverage gaps, and is it designed that way on purpose?

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.

How can I avoid or reduce IRMAA charges on my Medicare premiums?

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.

What happens if I delay Medicare Part A enrollment because I'm still on my spouse's employer plan?

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.

Can I use a health savings account (HSA) to pay Medicare premiums after I retire?

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.

My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?

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.

I went with Medigap because I travel a lot, but now I'm paying a fortune in premiums. Did I make a mistake?

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.

As a senior, what should I know about the differences between Original Medicare and Medicare Advantage before I choose?

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.

What are the most overhyped benefits of Medicare Advantage plans that seniors should be wary of?

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.

I'm confused about the different tiers in Medicare Part D plans. How do they affect what I pay for my medications?

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.

Is Medicare becoming more expensive over time, and will it ever be unsustainable?

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?

I'm considering genetic testing to assess my cancer risk based on family history. Will Medicare cover this preventive approach in my situation?

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.

I need help at home after my surgery. Will Medicare cover a home health aide or am I on my own?

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.

I'm a green card holder who's been in the US for 4 years and turning 65 soon. Am I eligible for Medicare?

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

I have a family history of colon cancer. Will Medicare cover more frequent colonoscopies for someone in my situation?

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.

Why does Medicare allow insurance companies to bombard seniors with confusing mail and TV ads?

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.

How much is spent on healthcare per year the U.S., and what does this amount represent per person?

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.

Why would you not choose a medicare Advantage plan?

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.

I need a hearing aid but I've heard Medicare doesn't cover them. Is there any way around this?

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.

I'm enrolled in a Medigap Plan F, and I'm not sure how my emergency room visits are handled. Is there a copay I should expect?

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.

My friend got her cataract surgery covered by Medicare, but they didn't cover the lens she wanted. How does that work?

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.

I thought I was covered during my snowbird months in Florida, but apparently not. What kind of plan do I actually need for that?

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.

My doctor recommended a bone density test. Is this considered preventive care under Medicare?

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

I'm confused about preventive services under Medicare. Which screenings are actually free?

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.

I'm homebound and need remote monitoring for my heart condition. What Medicare benefits might apply to someone in my situation?

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

I'm caring for my elderly parent with dementia. How can I get legal authority to manage their 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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Don't you think Medicare will eventually be privatized completely?

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.

How do Medicare Savings Programs help with Medicare costs?

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.

What's a Medicare rule or regulation that's outdated or unfair to seniors?

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.

I'm participating in a clinical trial for a new cancer treatment that uses personalized medicine based on my genetic profile. How does Medicare coverage work in this situation?

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.

What's the trade-off between a Medicare Advantage PPO and HMO when it comes to flexibility?

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.

I'm in the donut hole and can't afford my medications. What are my options right now before the 2025 changes?

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

I'm considering concierge medicine but already have Medicare. How would these work together?

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.

How is Medicare Advantage expected to evolve in the future?

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.

I've heard about new AI-powered diagnostic tools for early disease detection. Does Medicare cover any of these cutting-edge technologies?

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.

My friend says the new Medicare drug payment plan in 2025 will help with her expensive medications. Would it help me too?

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.

Are home modifications (like stairlifts) ever covered by Medicare for safety reasons?

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.

Can you explain how Medicare works with other types of insurance like Veterans Affairs benefits or employer plans?

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.

How does moving to a new state affect my Medicare enrollment timeline?

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.

Every year I stress over picking a plan and still end up surprised by the bills. Is there any way to just get peace of mind with Medicare?

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.

I've heard about IRMAA affecting my Medicare premiums. How can I find out if it applies to me, and how does it work?

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.

Can Medicare Part D deny coverage for a brand-name drug if a generic isn't available?

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.

I'm considering a smartwatch that monitors my heart rhythm for atrial fibrillation. Will Medicare help cover this type of wearable technology?

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.

When is the best time of the year to start looking at Medicare options?

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.

Will my Medicare plan work when traveling to Europe?

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.

So my friend told me I should just go with the cheapest Medicare plan. That sounds too simple - what am I missing?

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.

How do I budget for Medicare costs if I expect my health to decline in the next decade?

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.

What's the biggest mistake seniors make when choosing a Medicare Part D plan?

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.

Isn't it time for Medicare to completely overhaul how it approaches senior care?

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.

Does Medicare cover Ozempic and other drugs prescribed for weight loss?

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.

If I need hospice care in the future, can my Medicare plan cover it?

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.

I've heard that once you're on Medicare, you might not need life insurance as much. Is that true?

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.

My friend lives in a different city and has a much more detailed Medicare plan. Is their location dependent on their plan?

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.