Mark Cunningham, Medicare Insurance Agent

Answer: Seniors that are turning 65 need to be aware they should apply for Medicare 3 months before their 65th birthday. If they are still working, and have credible insurance coverage, they should only sign up for Medicare Part A. Part A does not have a monthly premium and this way they will not incur any enrollment penalties, for Part A, in the future. Once they are ready to retire they can add Part B to their Medicare card, which does have a monthly premium. Currently Part B, for 2025, is $185 per month and could be more depending on the earnings of the person applying for Part B.

Answer: The gaps come from Cost Share for Part A, Deductible of $257 and co insurance of 80/20% for Part B. In Part B you are responsible for 20% of the cost which is open ended. This means there is no maximum out of pocket. An example is a $60,000 hospital bill. You would be responsible for 20% or $12,000 of this cost. Provided everything billed is an accepted Medicare expense. I would be happy to go into this in more detail, please call me for further information.

Answer: Making the choice between regular Medicare with Medigap/Medicare Supplement or a Medicare Advantage Plan depends on individual healthcare needs, preferences, and financial situations. Regular Medicare with Medigap/Medicare Supplement provides notable advantages in terms of flexibility, coverage, predictability, and support. Choosing to prioritize these factors you may find regular Medicare with Medigap/Medicare Supplement to be a superior option. Understanding the differences and benefits of each choice is essential for making an informed decision about healthcare coverage.

Answer: Medicare covers many preventive screenings, often at no cost to you. Provided the physician accepts Medicare and the preventative screenings meet Medicare guidelines.

Answer: As a low-income senior, it can be challenging to afford prescription drugs, even with Medicare Part D. However, various assistance programs are available to help alleviate this burden. This document provides a comprehensive guide to specific assistance programs you can apply for to receive the help you need.

1. Extra Help from Medicare

To qualify for Extra Help, you must:

• Be enrolled in Medicare Part D

• Have an income below 150% of the federal poverty level

• Have limited financial resources

How to Apply

You can apply for Extra Help through the Social Security Administration (SSA) website, by calling SSA, or by visiting your local SSA office.

2. State Pharmaceutical Assistance Programs (SPAPs)

Eligibility requirements for SPAPs differ depending on the state, but they generally include:

• Residency in the state

• Enrollment in Medicare Part D

• Meeting specific income and resource limits

How to Apply

To find out if your state has a SPAP and how to apply, visit the Medicare website or contact your state's Department of Health Services. - https://www.medicare.gov/basics/costs/help/drug-costs

3. Pharmaceutical Company Patient Assistance Programs (PAPs)

Each pharmaceutical company has its own eligibility requirements, but they generally include:

• Having no insurance coverage or limited coverage for the medication

• Meeting specific income limits

4. Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including prescription drugs.

Eligibility Criteria

Eligibility for Medicaid varies by state, but typically includes:

• Having a low income

• Meeting specific resource limits

How to Apply

To apply for Medicaid, contact your state’s Medicaid office or visit their website.

Answer: As health declines, you may require more frequent medical visits, higher prescription drug costs, and possibly long-term care.

Make sure to:

• Review Medicare coverage: Ensure you understand what parts of Medicare will cover your anticipated needs.

• Consider supplemental insurance: Evaluate Medigap policies or Medicare Advantage plans offering additional coverage.

• Explore Medicaid eligibility: If you have limited income and assets, you might qualify for Medicaid, which can help cover costs not covered by Medicare.

Creating Your Budget:

• Calculate monthly premiums: Include premiums for Medicare Part B, Part D, and any supplemental insurance.

• Account for out-of-pocket costs: Factor in copayments, deductibles, and coinsurance for medical services and medications.

• Prepare for unexpected expenses: Set aside funds for emergencies or unplanned health interventions.

Long-Term Care Planning:

• Investigate long-term care insurance: Consider policies that cover nursing home care, assisted living, or home healthcare.

• Plan for home modifications: Budget for adjustments to your living environment to accommodate changing physical needs.

Additional Resources and Support:

• Financial advisors: Professionals can help create a personalized budget and explore investment options for covering healthcare costs.

• Licensed Agents Offering Medicare Plans: Licensed Agents can review your current plans and compare them with other plans in your area to ensure you have a plan that suits your needs.

• Medicare counselors: State Health Insurance Assistance Programs (SHIP) offer free counseling for Medicare beneficiaries.

Monitoring and Adjusting Your Budget:

• Review your budget: Assess expenses and adjust your financial plan based on changing health and economic conditions.

• Update your insurance coverage: Ensure your plan continues to meet your needs as they evolve.

Answer: Check for Licensing and Certification

The first step in verifying the legitimacy of a Medicare agent is to ensure they are properly licensed and certified. All Medicare agents must be licensed in the state where they operate. You can verify their license through your state’s Department of Insurance website. Additionally, agents must be certified by Medicare to sell Medicare Advantage and Prescription Drug Plans. Ask the agent for their National Producer Number (NPN) and verify it on the Centers for Medicare & Medicaid Services (CMS) website.

Verify Company Affiliation

Legitimate Medicare agents usually work for reputable insurance companies or agencies. Confirm the agent’s affiliation with the company they claim to represent. You can contact the insurance company directly to verify if the agent is authorized to sell their Medicare plans. Be cautious of agents who are vague or hesitant to provide this information.

Be Wary of High-Pressure Tactics

Legitimate Medicare agents will provide you with all the necessary information and allow you time to make an informed decision. Be cautious of agents who use high-pressure sales tactics or who insist on making a quick decision. This can be a red flag indicating that the agent may not have your best interests in mind.

Be on the lookout for red flags that may indicate an agent is not legitimate:

• The agent asks for your personal information, such as Social Security number or bank details, over the phone or online without a secure connection.

• The agent offers a plan that seems too good to be true or promises unrealistic benefits.

• The agent is unwilling to provide written materials or documentation about the plans they offer.

Schedule a Face-to-Face Meeting

If possible, arrange a face-to-face meeting with the agent. This will give you the opportunity to ask questions, review materials, and get a sense of their professionalism. A legitimate agent will be willing to meet in person.

Answer: While both Medicare and employer plans provide health coverage, they differ significantly in scope and benefits. Employer plans often offer comprehensive packages that include medical, dental, vision, and sometimes even wellness programs. Medicare, however, primarily focuses on medical and hospital insurance.

Medicare consists of several parts, each covering different aspects of healthcare:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care.

• Part B (Medical Insurance): Covers certain doctors' services, outpatient care, medical supplies, and preventive services.

• Part C (Medicare Advantage): An alternative to Original Medicare, offered by private companies approved by Medicare. Provides all Part A and Part B benefits and may include extra benefits like vision, hearing, and dental.

• Part D (Prescription Drug Coverage): Helps cover the cost of prescription drugs.

Employer-sponsored health plans typically provide a broader range of coverage options, including:

• Medical Insurance: Comprehensive coverage for doctor's visits, hospital stays, and medical procedures.

• Prescription Drug Coverage: Often includes a wider range of medications and lower co-pays.

• Dental and Vision Insurance: Coverage for routine dental exams, cleanings, vision tests, glasses, and contact lenses.

• Additional Benefits: Wellness programs, gym memberships, mental health services, and other perks.

While Medicare offers extensive medical and hospital coverage, it may not include all the benefits that an employer-sponsored plan does. Carefully comparing the two can help you determine the best path forward for your healthcare needs.

Answer: Medigap Plan G is a comprehensive supplement to Original Medicare (Parts A and B). It provides extensive coverage for various out-of-pocket costs that Medicare does not fully cover.

Medigap Plan G covers all costs not paid by Original Medicare except for the Medicare Part B deductible. In 2025, the Part B deductible is $257. This means that before Medigap Plan G begins to cover your knee replacement surgery, you will need to pay this deductible out of pocket, if you have already met the deductible for 2025 there will be no additional out of pocket expense for Medicare covered procedures.

The billing process for your knee replacement surgery will generally follow these steps:

• Your healthcare providers will submit claims to Medicare for the services rendered.

• Medicare will process the claims and pay its share of the approved amounts.

• The remaining eligible expenses will be forwarded to your Medigap Plan G insurer, which will then pay its share directly to the providers.

Once you have paid the Medicare Part B deductible, Medigap Plan G will cover the remaining costs of your knee replacement surgery, ensuring you have minimal out-of-pocket expenses. Always check with your healthcare provider and Medigap insurer to confirm specific coverage details and to understand exactly what to expect during the billing process.

Answer: The implementation of a $2,000 out-of-pocket maximum for drug costs is a crucial step toward improving the accessibility and affordability of healthcare. It offers financial relief to patients, encourages medication adherence, reduces healthcare inequities, and supports the elderly and disabled. By capping the out-of-pocket expenses for medications, this policy ensures that all individuals can prioritize their health without compromising their financial stability.

Answer: Creditable coverage refers to health insurance or prescription drug coverage that meets a minimum set of criteria defined by law or regulation. This term is used in the context of Medicare, the federal health insurance program for people who are 65 or older, as well as certain younger people with disabilities.

Understanding creditable coverage is essential for making informed decisions regarding health insurance, especially as you approach Medicare eligibility. By confirming whether your current health insurance and/or drug plan meets the necessary standards, you can avoid unnecessary penalties and ensure continuous access to essential medications.

Answer: Understanding Your Options Medicare Prescription Drug plans, also known as Medicare Part D, provide coverage for many prescription medications. However, navigating this coverage and ensuring affordability can be challenging. Discount cards and resources play a significant role in helping beneficiaries manage their medication costs. Here is an overview of how these tools can affect your Medicare Prescription Drug plan.

Discount Cards -

Discount cards are programs offered by various companies and organizations, providing discounts on prescription medications. These cards can be used at participating pharmacies to reduce the out-of-pocket costs for medications. While discount cards are not insurance, they can provide substantial savings.

How Discount Cards Work -

- Discount cards are generally available to anyone, regardless of whether you have insurance.

- The savings can vary widely depending on the medication and the pharmacy. It is essential to compare the discounted prices with your plan’s copayments and coverage.

- Present the discount card at the pharmacy when filling your prescription. The pharmacist will apply the discount, and you pay the reduced price.

Benefits of Discount Cards -

- Lower Costs for Non-Covered Drugs - If your Medicare plan does not cover a particular medication, a discount card can significantly reduce your costs.

- Savings on High Copayments - For medications with high copayments, a discount card may offer a lower price than your Medicare plan’s copayment.

- No Impact on Coverage - Using a discount card does not affect your Medicare coverage or benefits.

Programs that maybe available to you -

Extra Help, State Pharmaceutical Assistance Programs (SPAPs), Drug Manufacturer Assistance Programs, Charitable Foundations. To find out more please visit - https://www.cms.gov/medicare/health-drug-plans/medicare-prescription-payment-plan

Answer: 1. Determine Your Eligibility

Most people become eligible for Medicare at age 65. If you are retiring and will turn 65 next year, you should begin the enrollment process as early as three months before your 65th birthday. If you are already 65 or older, you may need to evaluate how your retirement affects your current Medicare enrollment.

2. Understand How Retirement Affects Coverage

If you’re retiring and currently have health insurance through your employer, that coverage will likely end when you stop working. You’ll need to ensure that you have Medicare Parts A (hospital insurance) and B (medical insurance) to avoid gaps in coverage. Even if you’re already enrolled in Part A, you’ll still need to sign up for Part B if it hasn't been done yet.

3. Enroll During the Special Enrollment Period (SEP)

For individuals retiring after age 65, retirement triggers a Special Enrollment Period (SEP), during which you can sign up for Medicare Part B without incurring late penalties. The SEP begins the month your employer coverage ends and lasts for eight months.

4. Consider Additional Coverage Options

Beyond Parts A and B, you may want to explore:

• Medicare Part D: Prescription drug coverage to help lower medication costs.

• Medigap: Supplemental insurance to cover costs not paid by Original Medicare, such as copayments and deductibles.

• Medicare Advantage Plans (Part C): An alternative to Original Medicare that combines Parts A and B, and often Part D, into a single plan.

5. Know Key Deadlines

Avoid gaps in coverage or penalties by knowing when to enroll:

• Initial Enrollment Period (if turning 65): Starts three months before your 65th birthday and ends three months after.

• Special Enrollment Period: Applies if you had employer-provided coverage and are retiring after age 65.

6. Contact Medicare or a Licensed Insurance Agent

Reach out to Medicare (1-800-MEDICARE) or your local Insurance Agent for personalized guidance on your specific situation.