Lilyana Uzdenova-Gomez, Medicare Insurance Broker

Answer: Medicare part D plans are required to cover prescriptions in all therapeutic categories. If there is no generic medication available and the only drug available for the given therapeutic category is a brand name medication, the plan has to cover it. The drug can be covered in any of the tiers available throughout the plan and the company or coinsurance will reflect the tier to which the medication belongs. The highest amount someone with a part D plan will pay for their prescribed medications in year 2026 is $2100 combined, not counting their monthly premium.

Answer: Your choice depends on your ultimate goal, budget and objectives. If you are comfortable paying a monthly premium for the flexibility of the supplement, and having a separate monthly premium for a stand alone Prescription Drug Plan then Original Medicare+Supplement + PDP is a great option. You will have no network restrictions and minimal pre-approvals.

If paying a monthly premium for a supplement and a stand alone drug plan seems pricey, and you are ok with seeing the network providers, as well as getting prior authorizations for your services, along with some extra benefits not covered by Medicare rolled into one plan, then Part C a good option. In either case, sitting down with an experienced advisor will help clear this up for you. Keep in mind that part C benefits change every year, as do networks. A reputable agent will not make a recommendation until he/she is familiar with your needs.

Answer: Original Medicare consists of parts A and B. Parts A and B do not usually cover drugs, unless they qualify for a few exceptions, injectibles, chemo, infusions or nebulizers under part B.

Drugs are usually covered under part D which has to be enrolled into as a stand alone plan or part C, combined with the health plan. When you choose the part D or part C plan you can search the carrier’s formulary (drug list) to find out if the specific inhaler is covered. Even though the carrier has to have a drug for each therapeutic category, they can choose which options to cover and make available.

Answer: You can verify if your new medication is covered by calling your current insurance carrier or by going to their website and searching their formulary. You can also go to the medicare.gov website and enter your medication info into the appropriate window to verify coverage. After you verified the coverage and the tier you can calculate your yearly expense for that medication and decide if switching to another carrier makes sense. Some carriers may cover the same medication at a lower cost in the same drug tier, or even in a different tier with significant difference in cost.

Keep in mind that if you have an MAPD, changing your plan due to drug costs will lead to the changes in overall benefits. Consider if those overall changes are worth the savings in drug costs. If unsure, consult a trusted advisor with expertise in locally available plans.

Answer: Hopefully, you had creditable coverage the entire time you qualified for Medicare but decided to delay it. You can find out if you qualify for retirement health benefits through your employer and if you don’t or they don’t seem to make financial sense, you would want to enroll into parts B and D within 63 days of leaving your employer coverage, even though part B penalty is only applicable if you have a full year coverage gap, part D penalty starts to accrue 63 days after you leave your employer coverage. Before you decide whether to choose a stand alone part D vs a Medicare Advantage part D plan you’d want to figure out whether you are a better fit for a Medicare Supplement vs Medicare Advantage plan. These two types of coverage are your two main paths of getting extra insurance in addition to Medicare and major issues happen from getting this first question wrong. An experienced local Medicare insurance expert can help you understand and navigate your needs better. Hope this clears it up a bit.

Answer: Yes, involuntary loss of employer sponsored coverage usually triggers a Special Enrollment period available for 2 months after the month of loss to join a Medicare advantage plan or a part D plan. In addition to that, if you delayed part B enrollment you have an 8 months widow to enroll into part B or parts A and B, if needed, without a penalty. Keep in mind COBRA doesn’t automatically extend the SEP, and part D penalty will still apply after the 63 day gap in creditable coverage. Always consult an insurance expert if you are unsure about your options.

Answer: The answer depends on whether your current employer offers creditable part B and part D coverage. If they do, the senior will not incur a late enrollment penalty if they decide to delay enrollment into Medicare parts B and D as long as they are enrolled into a creditable plan. It’s important to understand that there are two separate penalties and you have to have creditable coverage for both within 63 days of qualifying for part A. If the senior’s employer doesn’t offer creditable coverage I would encourage them to enroll into both parts B and electing a drug plan, either stand alone or built into a Medicare health plan. Always consult an expert for a full spectrum of options available in your area as well as your current benefits administrator for complete understanding of your employer benefits.

Answer: You should consider whether your employer will continue to offer creditable coverage for both parts B and D after you retire. If they do and it doesn’t cost more than medicare part B premium or offers benefits available nationwide without referrals you may want to consider staying with your employer sponsored plan instead of enrolling into part B and getting your own insurance.

There are other things to take into consideration which could not all be discussed in a few sentence response. I would highly recommend getting in touch with your local expert insurance broker and verifying your employer options with your current benefits administrator before finalizing your choices.

Answer: Most Medicare Advantage plans have network restrictions with HMO plans being most restrictive and PPO plans being more flexible. If you join an HMO Medicare advantage plan and your doctor is not in the plan’s network you will have to pay for 100% of the cost of that visit. If you join a PPO plan and the doctor is not in the network you may still be able to see the doctor if he bills your insurance, but your cost may be higher than it would be if you chose a network provider.

Ultimately, if your doctor is very important to you, make sure he is a part of the network or bills your insurance. Keep in mind that networks can change and doctors are not guaranteed to remain in the network.

Answer: Depending on where you live, you may have a low or no monthly premium for your plan, it may include extra benefits beyond the benefits of the original Medicare parts A and B along with the additional rules and regulations, and it should have a Maximum Out Of Pocket limit which original Medicare doesn’t have. You should also be able to find network providers, depending on where you are located, to take advantage of the lower costs.

Answer: My advice is to talk to an agent who is well versed on Medicare Advantage and Medicare Supplement plans. With the right plan you should know what your expenses are going to be based on your services , no surprises. For some it’s is Medicare Advantage for others it is Medicare Supplements. Both have advantages and disadvantages. I always explain the fundamental differences between both types of coverages, so my clients make their decisions based on their specific needs.

Answer: There is prohibition on unsolicited phone calls from Medicare Advantage and part D plan agents. If the phone call was unsolicited and you not only did not ask for a phone call from that agent, but did not consent to that call the call is reportable to the overseeing agency, CMS.

Even though Medicare Advantage plans sometimes offer perks or benefits outside of the scope of Medicare coverage, it is certainly misleading to claim that those benefits are “free” or are offered by Medicare itself. It is important to understand that switching your coverage just to get a specific perk is never a good idea without understanding the full spectrum of consequences.

Answer: In the world of insurance the coverage is usually obtained through payment of premiums, copays, deductibles, coinsurance or a combination of all. Often, when a plan doesn’t have a monthly premium it may have higher copays, deductibles and coinsurance than the plans with monthly premiums.

Always consider long term use of the plan with the potential healthcare expenses factored in.

Answer: I think that switching your helthcare plan based solely on the perk benefits is the worst decision. Not getting parts B or D in time are a close second. Assuming that you do not qualify for special election period after you missed an enrollment opportunity also carries potential harmful consequences.

Answer: “What kind of pathway would work better for my needs long term: Medicare Advantage vs Medicare Supplements?” is the question I encourage my clients to consider. Your income, your provider network, your traveling habits, your family health history-all may play into making the right decision.

Answer: Even though you should qualify for Medicare regardless of income, as long as you meet age, work quarters and/or disability qualifications, you may pay more than the standard premium for some parts of Medicare if you exceed certain income thresholds; or pay less if you qualify for the medicare savings program through limited income/resources.

Answer: The biggest risk may just be the fact that there is no limit to how high the actual out of pocket expenses could go if someone is experiencing significant health issues. Even though there are precise deductibles, copays, and coinsurance, those apply to each of the occurrences, no matter how much money someone has already paid in that year, or years before. Medigap can significantly reduce that potential expense, or even limit it to a relatively small yearly deductible, depending on the plan chosen.

Answer: Changing your resident state will trigger a Special Enrollment Period allowing you to choose the most appropriate option available in the new area. The SEP is usually available the month of moving and up to two months after changing the residence, it ends as soon as the new plan is elected.

Answer: Due to the Inflation Reduction Act of 2022 there have been some significant changes in the way prescription drug plans are now designed and the cost share attribution between the insured, the manufacturers and the insurance companies. As a result, most members who used to get into catastrophic coverage phase in the past and paid significant amounts out of pocket will save on their overall costs, while folks who are only taking a few generic medications may end up paying more.

Answer: Specific income and resource limits have not been confirmed yet, and will most likely be confirmed in the early 2026. There have historically been fluctuations in yearly income and resource qualifications to both mitigate the inflation and reflect budgetary concerns.

The process itself, for proving eligibility might require an extra step for some beneficiaries who previously had automatic status, they should receive gray letters asking them to confirm their income and resource qualifications.

Answer: How your concierge medicine will work with your Medicare depends on a few factors, some of the most important of which may be:

1. Does your doctor accept your Medicare plan? If he/she does, will he be submitting your claims to your plan or will he bill you directly and make the claims a part of your concierge care plan u see that agreement?

2. What exactly is included in your concierge plan? Is it private access to the Dr phone number and care/ consultations outside of the business hours, or is it all of the care that could usually be billable to Medicare?

3. If you decided to have the concierge care and original Medicare only, without a Medigap or Medicare Advantage plan, you are still responsible for paying original Medicare deductibles, copays and coinsurance. Those bills have No Maximum out of pocket Limit and can keep climbing up to significant amounts quickly when expensive care is needed.

In general, your concierge service will make it easier for you to see your covered provider and receive their expert guidance through your healthcare experience, but it will likely not protect you from Medicare related copays, deductible and coinsurance administered elsewhere, unless you have additional coverage, beside original Medicare.

Answer: The Medicare Summary Notice is the notice Medicare sends the beneficiaries with Original Medicare.

It should list the claims that Medicare has processed on your behalf and is usually mailed out on a quarterly basis.

Answer: Yes, both Medicare plan and costs could change based on someone’s income. If your dad’s income goes up and he was on a Dual Special needs plan, he could lose his Medicaid and eventually lose his qualification for his DSNP plan. During the deeming period he could be held responsible for higher copays or coinsurance as defined by his plan. After his “deeming period” he could be disenrolled from his current plan and lose coverage all together unless he chooses another plan before the end of his deeming period.

If your dad’s income goes down, and he now qualifies for Low Income Subsidy (extra help paying for prescription drugs) or even Medicaid, then a whole new set of plans may become available to him now (DSNP) depending on the are he lives.

In either case, whether losing or gaining Medicaid qualification, your dad qualifies for a special election period to choose a new plan that meets his current needs.

On the other hand, if your dad’s income goes up from under $100,000 a year to over $106,000 as a single individual, he may be imposed an IRMAA, which can significantly raise his Medicare part B premium, and his Medicare part D Premiums. The higher the income-the higher the Income Related Monthly Adjustment. If the income goes down again he could then request a reconsideration by filling out the proper form with SS.

Answer: Finding the right plan for my clients is like completing an intricate puzzle. It’s a thing of beauty when it all comes together. My happiest moments are actually when my clients share their stories of detected early and addressed in a timely manner concerns that were potentially lifesaving. Getting referrals is another big one, as it is the best compliment a client give, trusting me with the health of their loved one, or a friend based on how good of a job I’ve done for them.

Answer: Every case is unique. Not everyone is comfortable with committing to a monthly premium for their healthcare plan and potentially another premium for the part D plan in the sake of forgoing referrals, authorizations and networks. Many people rely on their generous MAPD drug and medical benefits while enjoying having access to the providers who are important to them within the covered networks.

You should be skeptical if you are dealing with an unethical agent who doesn’t disclose the pros and cons of each system, so you could make an informed decision.

Answer: Medicare was not meant and can not provide full coverage, as it is funded by payroll taxes and premiums.

It’s a baseline for the qualified consumer to add on to. Most consumers should be able to find a fitting plan between Medicare Supplement and the original Medicare, or the Medicare Advantage plans.

Answer: Before you decide, please find out if your employer coverage is considered to be creditable. If it is, you can delay your medicare, or at least, your part B and continue through with your employer coverage for as long as you qualify for it without having to worry about a penalty. Important detail, there are two separate penalties if your coverage was not creditable. One is for medical or part B, another one is for part D. If your coverage is credible those penalties do not apply and you can turn your part B on when you are ready to leave your employer plan.

Answer: Step 1: I would make sure that all of the qualifications for home healthcare are met: the person is homebound, daily skilled care is required, there is a realistic chance of improvement, you could not get that care on the outpatient basis, and the doctor Properly Certified the need.

Step 2: If all of the conditions are met, you have a great case for appealing that denial. You could simply take that case from a simple Redetermination and Reconsideration case by contacting Medicare all the way to Office of Medicare Hearings and above.

Answer: Your agent should have gone over the exact benefits including the coverage limitations. Some Medicare advantage plans have monetary allowance limits, others have benefit frequency limits or both. Many of the plans will also use verbiage defying preventive, basic and comprehensive dental benefits. Just getting a “dental coverage” doesn’t mean you are getting more than preventative care which usually only includes, exams, X-rays and possibly cleanings.

When you work with an agent they should go over the summary of benefits and help you understand exactly the coverage you are choosing with all of its limitations.

Answer: Hello, too many variables to answer definitively. A higher premium doesn’t always mean lower copay, unless you were choosing between Medicare Supplements only and did not consider multiple Medicare Advantage plans as well.

If you were only choosing between supplements, then you probably made that choice for a reason. If you were relatively healthy at the time of your enrollment you may have thought that you would be saving some money in lower premiums.

When it comes to Medicare Supplements, it’s safe to say that if you’d like the comfort of knowing that your doctor bill will always be $0, as long as the doctor is participating in Medicare, and you met your yearly deductible, you will pay for that comfort in higher premiums, which come every month, whether you see those doctors or not. Are you ok with that monthly commitment?

You may have opted for a high deductible supplement, in which case, once your deductible is met, you should no longer be getting “surprise” bills. However, you may have saved a significant amount in premiums and only incurred the bills when you needed to see a doctor.

Ultimately, I’d ask my client if they are comfortable with “prepaying” for the care they may or may not need vs assuming some of that risk personally. Many times healthier individuals are more inclined to choose lower premium plans with higher deductibles, copays and coinsurance while folks with chronic conditions or family history of serious diseases will opt for paying higher premiums for that extra peace of mind. Every case is unique and there is no standard answer.

Answer: For me insurance is all about building relationships with trustworthy people. With hundreds of thousands of seniors being scammed online and over the phone every year, I love giving my clients peace of mind that their information is safeguarded and that their agent is looking out for their best interest by helping them compare multiple plans, while minding complex details like numerous prescriptions and providers in mind.

Eventually, AI may replace the skill set we as agents work so hard to build and hone year after year, but it will never replace the human care and connection we establish with our clients.

You should work with me if you’d like security of your personal information, personal approach to addressing your needs, concierge experience with issue resolutions that allows you to either minimize or completely bypass dealing with customer service, continuous updates on the Medicare system and plan changes, and if you simply enjoy a good cup of coffee with a genuine person.