Michael Andrews, Medicare Insurance Broker

Answer: The question is, what are the disadvantages of an HMO? So, the disadvantage of an HMO versus, say, a PPO is that with an HMO, you do not have the option to go out of network. Depending on the plan, you may be able to go out of network in an emergency situation. But if you wanted a second opinion and your doctor does not take the HMO, you would not be able to see that doctor and have insurance pay anything towards it.

If you have a PPO, the doctor still has the ability to refuse to charge your insurance, even though you have a PPO. However, if he or she agrees, it will most likely be at a higher cost share.

So, for an example, say if you have an HMO plan and your copay is $50. However, if you're out of network, the copay instead of being $50 could be something called a co-insurance. And let's say that could be 20% or more, depending on the situation. Hopefully, this helps for you.

Answer: So when I came across this question, I definitely had to make a quick video because it's a pretty simple answer. The question is, I'm on a Medigap Plan G, and I'm curious how my upcoming knee replacement surgery will be billed. Does the plan cover it after all? Does a plan cover it all after my deductible?

The answer to that is yes. If you are getting this surgery done at a Medicare-approved facility and it is medically necessary, the only thing you have to pay for with a Medicare Plan G is a $283 deductible for this year. After that, you won't pay anything.

Answer: So the question is, is original Medicare or Medicare Advantage better? What do you recommend, one over the other? As far as making a recommendation, I think the best way to compare the two would be to look at a Medicare Advantage plan with or without drug coverage versus original Medicare with a supplement.

Now, with original Medicare and a supplement, you can see any doctor in the country that you choose. You'll pay an additional premium per month, but you have very little to no out-of-pocket expenses when you need to use it. So you'll pay more per month, but there's more predictability in what you'll pay.

Medicare Advantage plans typically mean you get what you pay for. There are zero premium plans. However, there are higher copays, higher coinsurance, and a lot more network restrictions.

As far as one being better than the other, it really depends on your specific situation, needs, and preferences. And as always, I'm here and happy to help.

Answer: So the question is, do I need extra protection like critical illness insurance if I am on Medicare? Regarding having to have extra protection, you don't have to. There is no penalty for not having this extra protection. However, it is imperative that you find coverage to help protect against those non-Medicare approved expenses, which typically happen a lot with the big three: cancer, heart attack, and stroke. So normally, in most circumstances, we do suggest offering critical illness packages as part of your Medicare portfolio.

Answer: Questions I want to ask: If I went to a free Medicare seminar and it felt like a timeshare pitch, are any of those events actually helpful? I will say that they are. I do those events myself. A lot of times, I'll do them at senior centers. I've done a few of the dinner seminars. I will say that it depends on the person that's presenting. It depends on the company that's presenting. You always want to make sure that you're going to speak with somebody that comes from an education approach first. Because nobody likes being sold to. You're going to these events for education. Normally, what happens is you go to the events and you have the option to fill out a call back reply or you can call the person by getting their business card. A lot of times, that's how I really do it. I just say, "Hey, my cards are on the table. If you're interested, you can call me. Or if you want me to give you a call, I can fill out this form." So it really just depends on where you go. But I think it is good because you can get a lot of your basic questions answered. And sometimes it's just beneficial to go for your spouse as well. That way, you can be on the same page when the time comes to make those decisions. I hope this helps.

Answer: The most frustrating misconception that I see clients struggle with is having to take Medicare when they turn 65, no matter what, to avoid penalties. They hear this from their friends or family. A lot of times, I'll tell them it really just depends on your situation.

For example, if you're gonna continue to work and say you have an HSA, your best bet is to not take Medicare at all. However, if you're gonna continue to work and it's just you and the insurance, you know, low cost and it fills your needs, you might want to take Part A and hold off on Part B, because Part A is normally free. Once you get your Medicare number generated, it's a little easier to get Part B active when the time does come.

The biggest thing for getting Part B active later on down the road is that there are a few extra steps involving Social Security and the HR department of your company to fill out some forms that’ll allow you to avoid those late penalties.

So the biggest advice that I can give is just know your enrollment windows, reach out to somebody, talk to somebody, get a conversation or a Medicare game plan in place. I always recommend about six months out is usually a sweet spot to start having that conversation. And for those that are planners, maybe even up to a year. I hope this helps.

Answer: So with a PPO plan, it does give you the flexibility to go out of network if absolutely necessary. However, the provider can still decide whether they're going to take the insurance or not. The PPO could be an option if you want to get a second opinion that maybe is not in network and they're willing to bill out of network. But usually, with the contracts, there's no contract with that specific hospital system, so you'll pay it on a network amount.

So if you, for instance, are going to get a surgery done normally with a plan that's in network, maybe you'll have a few hundred dollars copay. However, if you're out of network with a PPO, as an example, sometimes with those plans, you'll pay 20, 30, 40, or even higher percentage of that until you hit the maximum out of pocket. Just keep in mind that each plan typically has its own max out of pocket. If it's an in-network versus out-of-network plan, sometimes you'll see two different max out of pockets for plans.

Regarding HMO, typically with HMO plans, you don't have the extra flexibility. However, if you are in a situation that is an emergency, you will be covered regardless if you're an HMO or PPO or not. I hope this helps.

Answer: So my belief is that the most important thing regarding what to know about Medicare and its parts is really your enrollment windows. When you have to take a plan, when you have to take Part B, and when you don't have to take anything at all.

As far as the individual parts, Part A is the hospital coverage. It basically covers your room and board while you're in the hospital, or if you're in a skilled nursing facility. It also covers hospice as well as blood in the hospital.

Medicare Part B is known as your medical coverage. But what that really means is that it covers everything else outpatient. So those are all your doctor's visits, surgeries, blood work, EKGs, MRIs, anything that would be outpatient, including durable medical equipment.

Part C is another name for Medicare Advantage plans. Basically, you can get on a private plan and get your Medicare coverage that way. And then Part D is for prescriptions and drugs. Part D plans can be standalone, meaning that if you just stay with original Medicare and get a supplement, you're most likely gonna get a Part D plan.

However, if you decide to go on a Medicare Advantage plan, those plans typically have a prescription drug plan embedded into them already. So you do not have to choose a separate drug plan. I hope this helps.

Answer: Normally if you have Original Medicare your doctor decides what is Medically necessary as long as it corresponds with Medicare guidelines. Usually there are no referrals or prior authorization requirements needed. If you have a Medicare Advantage plan, a private insurance company is the primary payor for your healthcare and some services may require prior authorization, step therapy, and referrals may be necessary.

Answer: A couple disadvantages of a PPO are that usually the copays or cost share beneficiaries would have to pay tend to be higher if they go out of network and also some doctors may elect to not accept the out of network benefits and you'd have to pay the full amount.

Answer: The new Medicare plans become available for general public knowledge October 1st but no applications can be submitted until October 15th. I think a great time to start preparing for AEP would be in September just to make sure plans are in place, however, at the very least start October 1st.

Answer: Original Medicare does not cover hearing aids. Some Medicare Advantage plans do offer various coverage amounts for hearing aids.

Answer: Good afternoon. The question is, I'm worried about choosing the wrong plan and being stuck with it. How often can I change my Medicare coverage? There are a couple of situations where you can change your plan. The most common is the Medicare annual enrollment period, which is between October 15th and December 7th. You can make any change to your Medicare plan during that seven-week window, and whatever change you make will be effective on January 1st.

Now, there are certain circumstances revolving around Medicare Advantage plans. If you join a Medicare Advantage plan when you turn 65, as long as your Part A and Part B start on the same date, you have what's called a trial period. You have up to 12 months to decide if you want to continue with the plan or disenroll and get a supplement or a prescription drug plan.

For most people, the main opportunity to change is in the fall, between October 15th and December 7th. There are a couple of other opportunities, especially for those who might have changed their plan mistakenly over the phone. Sometimes you can make certain changes between January and March.

One good thing about Connecticut is that it's a guaranteed issue state. If you choose an Advantage plan instead of a supplement and want to go back to a supplement after maybe sustaining a chronic illness, you can do that without any medical underwriting. So that is one great thing about Connecticut. Thank you very much. Hope this helps.

Answer: Does Medicare fully cover nursing home care, and are there alternatives? Medicare is health insurance designed to provide for your medical needs. It's not necessarily custodial care, meaning long-term care. Most people, if you find yourself in a situation where you need to be in an assisted living facility or a nursing home, those are usually taken care of by long-term care policies.

Now, if you don't have a long-term care policy and, say for instance, you go to the hospital and then to a rehab facility for 50 days, Medicare will cover you up until day 100 at a skilled nursing facility until they decide to stop paying. That's when you become more of a long-term care type of situation. Sometimes you have to spend down, but the answer is Medicare does not cover nursing home care. If you need to go to rehab, it could possibly give you coverage for up to 100 days.

So, the alternatives are long-term care policies. There are certain programs, depending on the state you live in, that could pay a loved one to take care of you. I know you can't be a spouse for that. That's pretty much it. Thank you.

Answer: Good morning, everybody. The question is, I'm planning to delay Social Security until age 70, but I'm turning 65 soon. How does this affect my Medicare enrollment? Typically, if you're already collecting Social Security income, you would normally expect to receive your Medicare card, Parts A and B, in the mail about two to three months, sometimes even four months, before your Medicare actually starts.

Now, for most people who are not taking Social Security, what they need to do is actually go online to ssa.gov to apply for Medicare that way. If you have insurance through an employer and you're going to continue to work, you don't have to take Medicare as long as you have insurance through an employer that's got 20 or more employees. But basically, if you are planning to delay your Social Security, just know that you need to actively apply for Medicare Part A and Part B. It does not happen automatically.

Answer: Hi there! The question is, my friend gets Silver Sneakers with her plan, and I don't know how we're both paying for Medicare and getting such different stuff. So, Silver Sneakers programs are not what you get with your red, white, and blue card. The Silver Sneakers program is a gym membership that you can access at different gyms that accept Silver Sneakers, and you find this mostly on Medicare Advantage plans.

Now, it's not a reason to switch insurance, but it is also a pretty cool perk. It allows you to go to any gym that accepts Silver Sneakers at no cost, so it's great if you're gonna be traveling or if you're gonna see a friend in a different town. It's a great tool to help keep healthy, but again, it's not part of Original Medicare, nor is it a reason to switch off of Original Medicare necessarily if you have it. Hope this helps!

Answer: Hi there, good morning. The question is, a Medicare supplement broker told me about extra lifetime reserve hospital days. What are those and how do they work?

So, simply put, with Medicare Part A, that's your hospital coverage from day zero through 60. You just pay your deductible for the benefit period, which is about $1,600; it's a little more this year. Once you hit day 61, while you're in the hospital, from day 61 through 90, you're paying about $400 a day.

Once you hit day 91, you get into what's called your lifetime reserve days. Basically, you have 60 days that will give you hospital coverage. You are going to pay a little more than $800 a day, and if you use all those days, they are gone for your lifetime.

So, say for instance you're in the hospital and you end up being there for 150 days. You've already used your 60-day benefit or lifetime reserve days, and then five years later you go back to the hospital. The most that you can get Medicare coverage for would be 90 days, 'cause you've already eaten into your lifetime reserve days.

Thank you for listening, hope this helps!

Answer: Hi, the question is: what is the Medicare Advantage 5 Star Special Enrollment Period, and is this different from OEP and AEP? Yes, the 5 Star Enrollment Period is basically if there's a Medicare Advantage plan in your area that's a 5 Star, meaning it has a rating of 5 stars, you can enroll in that plan at any time of the year. Here in Connecticut, we currently do not have any 5 Star plans that most people can enroll into, but if we ever get one, then you'd be able to enroll in that one at any time of the year. Thanks again!

Answer: Hello, the question is, do your clients use Medicare Advantage over-the-counter drug cards? How does that work? The OTC benefits that we hear about on a lot of the plans are not set in stone and guaranteed, meaning that they do change every single year. It's not necessarily used for prescriptions; it can be used for over-the-counter medications, such as cold medicines, flu medicines, stuff for GI issues, and different things like that. Original Medicare does not have these benefits. These are the benefits that you would receive from a Medicare Advantage plan, and not all Medicare Advantage plans necessarily have this benefit. But as long as your doctors and your prescriptions fit well into whatever plan you're looking at, and that plan also happens to have an OTC benefit, then it's just icing on the cake. But my advice is to not just choose a plan based on OTC coverage. Hope this helps!

Answer: I hope you're doing well. The question is, can you explain how Medicare works with other types of insurance, like Veterans Affairs benefits or employer plans? Absolutely. Medicare and VA benefits are completely separate entities. If you go to the VA and use your VA benefits, when you go to any doctor outside of the VA or hospital, that's where your Medicare comes into play.

Now, there are a couple of caveats. Say, for instance, you need to get a procedure done, and there's only a civilian hospital that can do it. Sometimes the VA benefits will kick in and help pay for it. So basically, they're two different entities that don't really work together, but they're side by side. I know a lot of vets will go to the VA and maybe want to get some Medicare just in case something happens with what the VA provides.

With employer benefits, if your employer has 20 or more employees, your employer plan is primary, and Medicare would be secondary. A lot of times, most folks who continue to work past 65 and have a larger employer, with 20 or more employees, won't sign up for Medicare A and B. They'll either sign up for Medicare Part A unless they have an HSA. If they have an HSA, you don't want to sign up for any part of Medicare until you're ready and no longer have health insurance. For employer plans, if your employer plan has 20 or more employees, Medicare would be secondary, and your employer plan would be primary. Hope this helps.

Answer: So the question is, what do I do if I can't afford my Medicare premiums? Well, Connecticut and most states have their own program called the Medicare Savings Program, and it's for individuals who are below a certain income. Each state has its own requirements. I know in Connecticut, they have requirements that are just income-based. So as long as your income is below a certain amount, you can get some assistance paying for your Medicare premiums.

Just as an example, if you're single and your income is about $3,200 a month or less—and yes, that is gross income, including all of your Social Security and any distributions you're receiving from a 401(k)—then if that total amount is below $3,200, we can help you get on the savings program. If you're married, that income threshold is slightly higher. There’s no cost or anything like that, and it would help pay for your Part B premiums and sometimes your Medicare copays. Hope that helps!

Answer: There are some Medicare Advantage plans that may offer food card benefits, however, these are usually found with Special Needs Plans and not all Medicare beneficiaries qualify. Original Medicare does not cover groceries or other related products such as over the counter benefits.

Answer: The major red flag is if the caller asks for your Medicare number fairly quickly into the call. The first questions should be about your doctors and prescriptions as well as questions about the coverage you are seeking. Working with a local broker in your community is always a great option.

Answer: If you have a prescription drug plan either through a Medicare Advantage plan or a stand alone part D plan, the most you will be responsible for is $2,000 out of pocket for the year as long as your prescriptions are in the formulary of the plan.

Answer: Some people wait because they think they will automatically enroll into Medicare without having to do anything. Automatic enrollment occurs only if you are already collecting social security retirement income. It is recommended that you meet with a local expert that can help you create a Medicare gameplan so that way it is a much smoother process.

Answer: Yes some do! There are plans depending on where you live that may offer alternative therapies such as chiropractic and acupuncture. It is important to keep in mind that you can only use alternative providers that have a contract with the insurance company of your plan.

Answer: First find out if enrolling into Medicare is the best thing to do. If you have a younger spouse or child on your insurance or if you plan to keep working, you may not want to enroll into Medicare yet. If you need to enroll into Medicare, you can through ssa.gov or call your local social security office to make an appointment.

Answer: The biggest mistake I've seen is a beneficiary applying for part B retiring after 65 without submitting the correct forms that will prevent late enrollment penalties. It is important to begin the application process with social security 3 months prior to needing your part B to start.

Answer: In my opinion, the biggest disadvantage of the Medicare Advantage plans is the ability for doctors and hospital networks to undergo contract negotiations which may leave the client out of network for the rest of the year.

Answer: I personally like to physically draw out the A, B, C, D's of Medicare on paper to help create an understanding of part A and B as well as the additional options you have. I educate on all the available options specific to my client's needs so that way I help empower them to make a properly informed decision.

Answer: Local agents tend to be more familiar with their state's doctor and hospital networks which can be very helpful when reviewing Medicare plan options.