Michael Wallner, Medicare Insurance Agent

Answer: Not all doctors except all Medicare Advantage Plans. If a doctor does not participate with your Insurance Plan, they have no legal obligation to accept you as a patient, (unless it is in an emergency room). If a doctor does not participate with your insurance plan but still agrees to treat you, you will likely have higher out-of-network cost-share for the services you receive. Many insurance carriers offer what is called a PPO Insurance Plan that offers both in and out of network benefits. A Medicare Insurance Agent can help you determine what Medicare Insurance Plans your providers participate with in your area.

Answer: The areas of biggest difference between a Medicare Supplemental Plan and Medicare Advantage plans are:

- Monthly Premium

- Potential Out-of-Pocket Cost, (Deductibles, Co-pays and Co-insurance)

- Provider Network

- Extra Benefits, like RX, Dental, Hearing, Vision coverage.

Whether one is better than another is very heavily dependent on your overall all health, need for services and types of services needed, need for cancer or specialty care, your location and whether you travel regularly etc., etc..

With Medicare Supplemental Plans you will likely have a higher premium and little to no out-of-pocket costs when you receive services, no restrictions on where to receive services, but no extra benefits like RX, Dental, Hearing and Vision, etc.. With a Medicare Advantage Plan you will likely have a zero or low monthly premium and extra benefits, but you may also have a limited network and a potential for a lot of out-of-pocket costs when you receive services. Your best approach is to review your specific situation and needs with a licensed Medicare Agent that can help you identify the best options available to you in your geographical location.

Answer: Life insurance does not effect your Medicare eligibility or premiums. Eligibility is determined by age, work history of you or your spouse or disabilities you may have. Cost is determined by your gross income from two years prior and may be additionally increased by a penalty if you do not sign up for Medicare during your IEP, (Initial Enrollment Period) and do not have creditable coverage.

Answer: The most common penalties from Medicare are the potential late penalties associated with Medicare Parts B and D. If you do not sign up for Medicare Part B and D during your IEP, (Initial Enrollment Period), and you do not have other creditable coverage, your premiums for Part B and D will be increased by a percentage when you eventually sign up. The longer you delay signing up, the bigger the penalty will be. You IEP, (Initial Enrollment Period), is the three months prior to your 65th birthday month, your birthday month and 3 months following your 65th birthday month. Creditable Coverage is defined as healthcare coverage that is as good or better than standard Medicare coverage. Don’t delay, talk to a local insurance agent today to avoid paying more for your health insurance.

Answer: Yes, Medicare covers Outpatient Observation Days under Medicare Part B coverage. Under Part B, there is a 20% Co-insurance. Inpatient care is covered under Medicare Part A coverage and typically requires a deductible that is close to $2,000 per each unique Inpatient Admission. Whether your are treated as an Inpatient or Outpatient is based on several factors such as diagnosis, treatment, expected length of stay and other medical criteria that supports an admission order written by your doctor.

Answer: Yes, Medicare covers limited in-home care for dementia patients, but it does not cover long-term, non-medical custodial care (such as help with bathing, dressing, or 24/7 supervision).Medicare will pay for in-home care if the patient meets specific criteria and needs short-term medical care requiring skilled nursing assistance as order by a doctor. Typically Medicare is not a financial resource when only supervision is needed.

Answer: Medicare does cover shoulder replacement surgery that is considered medically necessary as per your doctor’s order. This is a standard surgical procedure similar to knee and hip replacement surgery, many times provided on an outpatient basis. Remember, Traditional Medicare only covers 80% of the cost for Outpatient Medical Services. 20% is due for the patient. If the procedure is done in an Inpatient setting, a deductible will be due… about $2,000 in 2026.

Answer: Yes! Work with a local agent that can help you research the history of insurance plans available in your area. Many insurance carriers routinely change plan benefits and structures. An agent can also help you learn more about the strength of an insurance carriers network in your area. Many insurance carriers do not pay their claims timely or accurately. Many providers may not accept an insurance plan because of on going issues and the reputation the insurance carrier has in your market. An insurance plan with a great price and great benefits is worthless if the insurance carrier does not have a solid network with the providers and healthcare organizations you prefer to use for your care. Do not base your selection of an insurance plan on the “extra” benefits such as dental, hearing and vision coverage as these benefits and networks are usually not very good.

Answer: You can sign up for Medicare Part A and Part B online through the Social Security Administration (SSA) website during your 7-month Initial Enrollment Period (3 months before to 3 months after your 65th birthday). The process takes about 10 minutes, and you will need to create a login.gov account.

Several ways to Enroll:

- Online, visit SSA.gov and click "Sign up for Medicare".

- Phone: Call Social Security at 1-800-772-1213

- In-Person: Visit your local Social Security office.

Answer: I encorage my Senior Clients to try and consider their MOOP (Max Out-of-Pocket) expenses when considering a Medicare Advantage Plan. Most people focus on Monthly Premium and extra benefits and overlook the potential effects of the deductibles, co-pays and co-insurance fees if they were to get ill. Some services, such as Cancer Infusion services, have high Out-of-Pocket fees. You really need to consider the worse case scenario and factor in over all health, family history and other factors, when choosing the right health plan for you.

Answer: Yes, you will receive a late penalty for your Part B and Part D premiums for not signing up for Medicare when you turn 65. You can avoid these penalties by being able to demonstrate that you have creditable coverage, (Health Insurance and Prescription Drug Coverage that is as good or better than Medicare Coverage). If you have creditable coverage, you can sign up for Medicare at any age after you lose that creditable coverage.

Answer: You can enroll in a Medicare Part D plan through the Medicare.gov website. You will want to be careful and make sure you verify that all of your medications are covered and compare your out-of-pocket costs between plans as they will vary. Also make sure your preferred Pharmacy is in network as well. Even though the insurance carriers no longer compensate Medicare Health Insurance Agents to enroll Medicare beneficiaries into their Part D Plans, some agents may be willing to offer their time and expertise in finding a plan that fits your needs. This process can be time consuming if you have a lot of prescriptions, so start early and be sure to have an organized list of your prescriptions and the dosages ready to enter when you do your research. Remember, not signing up for Medicare Part D when you are eligible even if you don’t have any prescriptions will result in a late penalty when you sign up later on down the road.

Answer: Medicare Part B covers cost for your providers and outpatient preventive, diagnostic and treatment services. Medicare Part B will cover 80% of these costs. You will be responsible for 20% of the cost, with no annual cap on what you might have to pay. Considering how expensive these services are, the 20% could be substantial, easily hundreds to thousands of dollars. A Medicare Gap plan or a Medicare Advantage plan can help minimize your out of pocket cost for all services, Part A, Part B and Part D.

Answer: Yes, Medicare Advantage Plans are defined by county. Although many carriers offer similar plans in most areas, the specific plan name, benefit and cost structure as well as provider networks will differ by County.

Answer: All Medicare Agents are required to complete State required education and testing in order to receive their license. In addition, agents must complete individual payer education and testing before they are appointed by the payers and able to represent payer products. Medicare also requires agents to complete annual education and testing on regulatory updates, ethics and compliance. Many agents also have additional work experience that adds to their expertise in the Medicare Insurance space. It is a good idea to ask about an agents work history and years of experience to get a better understanding of their background and level of expertise.

Answer: Enrollment in Medicare is individual unless you were enrolled under a Private Employer Sponsored or Union Plan. Losing your spouse would not normally increase your premium under Traditional Medicare. If you were enrolled under a private employer or union plan, you should contact the plan administrator directly.

Some Medigap Policies offer a Household Discount. If you are referring to an increase in the premium for a Medigap Plan, it is likely you may have lost the household discount on your policy due to your husband’s death.

Answer: It is true that Premiums for most Medigap Plans are higher than the premiums for most Medicare Advantage Plans. However, a few of the advantages of having a Medigap Plan are:

- Essentially an unlimited Network. You are able to seek care from any Provider that participates with Traditional Medicare anywhere in the country.

- Minimal to Zero out-of-pocket expense. Most Medigap plans cover all or the majority of any out-of-pocket expense related to Co-pays, Co-insurance and deductibles.

- Medigap Plan benefits do not change. Medicare Advantage Plan Benefits and Networks are constantly changing.

Answer: Understanding the basics of Medicare Insurance is key to selecting the option that meets your needs best. Educating clients on the basics and the various options should be an in-person meeting whenever possible. This education may require several meetings. It is key that your clients understand their options and related risks and costs. This process should not be rushed through with new clients. Plan an initial meeting and follow-up to answer the many questions that are likely to develop after the initial meeting.

Answer: You are able to change your Medicare Advantage Plan during the Annual Enrollment Period, ( AEP, October 15 through December 7th), for an effective date of January 1. You are also entitled to change your Medicare Advantage Plan during the Open Enrollment Period, (OEP, January 1 through March 31st) of each year. If your Hospital non-participation with your Insurance Plan is a new development, for example the Hospital recently terminated its agreement with the insurance plan, you may also be entitled to a Special Election Period, (SEP), and allowed to switch your plan. A Medicare Insurance Agent can help you determine your eligibility to switch your plan and other options that may be available to you.

Answer: Original Medicare includes deductibles for inpatient services and only covers 80% of outpatient services with no maximum out-of-pocket limits. Original Medicare also does not include any coverage for prescription medicines. A Medicare Advantage Plan may have deductibles, co-pays and co-insurances but does have a maximum out-of-pocket limit… so you know what your worse-case scenario could be. Medicare Advantage Plans also include Prescription Drug Coverage and other benefits like dental, hearing and vision, many times all at the same monthly premium you would pay for Original Medicare. If you are not considering Original Medicare WITH a Medigap Plan, a Medicare Advantage Plan is your best value in most cases.

Answer: When you turn 65 and are collecting Social Security, Medicare Part A, (Inpatient and other related coverage) will start, If you also want Medicare Part B, (Outpatient/Physician coverage), to start at that time, you need to initiate that with the Social Security office. You have a 7 month window to initiate Medicare Part B coverage, three months prior to your birthday month and three months after your birthday month. Please note Medicare Part B will have a monthly premium that you can have billed to you, or deducted from your social security check each month. Also, please keep in mind that there are Deductibles for Medicare Part A coverage and Medicare Part B only covers 80% of your medical costs.

Answer: A Medicare Agent will get paid a commission by the Insurance Carrier of the plan the agent helps you enroll in. The commission paid to the agent has no effect on the amount you will pay for the insurance plan. Using an agent is free to you. Take advantage of an agent’s expertise to help you find the best insurance plan for you. Agents have in depth knowledge and access to information that is difficult to find on your own.

Answer: Medigap Plan F covers all expenses for Part B, (Outpatient, including Emergency Room), Services not paid for by Traditional Medicare. You should never have a co-pay for Emergency Room care under Medigap Plan F.

Answer: Using your Zip Code, search for an Independent Medicare Agent near you on the Medicare Agent Hub. Agents can help you understand the options and associated costs for Medicare Health Insurance available in your area. There is no cost to you when you use a Medicare Agent.

Answer: A Medicare Medigap Plan is portable and would not need to change. If you have a Medicare Advantage Plan, you will need to switch to local Medicare Advantage Plan at your new residence, or change to a Medigap Plan. If you have a separate Part D RX Plan, that will also need to be changed when you relocate. If you only have Traditional Medicare A and B, nothing will need to change. Search for a local Medicare Agent at your new location to help you determine what the best, most cost effective options are for you.

Answer: Yes… you can get a Medigap Plan with Guaranteed Acceptance if you lose your Employer Coverage and you are 65 or older. Note, your Employer Coverage needs to be Creditable Coverage, as defined by CMS, (Center for Medicare Services). Your Human Resources department will need to complete a form verifying your Creditable Healthcare coverage.

Answer: Working with a Licensed Medicare Agent gives to access to free information and advice. Agents are required to complete annual training with Medicare and each insurance carrier and have a high level of expertise with the insurance plans and their benefit structures. A good agent should keep you informed about any changes within the healthcare industry, your health insurance carrier or your plan that will affect your benefits and/or costs. Agents are also aware of Provider/Carrier relationships and potential issues that could affect your access to care. Agents are not paid by you the beneficiary. Your costs are not affected by whether you use an agent or not.

Answer: Yes, heart medications and implantable devices like pacemakers are covered under Medicare. Remember Traditional Medicare only covers 80% of the cost for outpatient services and many medications will have a co-pay or co-insurance that you will need to pay. Inpatient care will also have a cost share that must be paid by Medicare beneficiaries as well.

Answer: Start early and seek assistance from a trusted source in your local community. There is no obligation or costs to meet and discuss your healthcare options with a Medicare Agent. Key items to consider are whether your providers are in network and your important prescriptions are covered.

Answer: If you are relatively healthy, a Medicare Advantage plan may be a good option for you. There are many Advantage Plans that have a zero or very low monthly premium. These plans also offer extra benefits, like Dental, Hearing and Vision and include RX. These plans do have co-pay and Co-insurance provisions, but these only apply when you are receiving Medical Services.

Answer: The biggest disadvantage to Medicare Advantage Plans is that the Network of participating providers may be limited. If you use out-of-network providers, your cost share is likely to be higher. Some high cost specialty services like chemo and infusion therapies usually have a high co-insurance, like 20% in most Medicare Advantage Plans.

Answer: A Medicare Agents has insight on the payer/provider relationships that can help you avoid signing up with an insurance company that has provider network issues.

Agents know the ins and outs of the benefit details that may not be easily identifiable on insurance company communications.

You don’t pay the agent, so why not tap into free advice and expertise.

Answer: A few things to consider when considering a Medicare Advantage Plan:

- Networks may be limited. Some plans offer out-of-network benefits, but usually at a higher out-of-pocket cost to the member. Also be careful not to select a Medicare Advantage Plan that your primary provider network may not even except.

- Many of the Extra Benefits, Like Dental, Hearing and Vision have limited allowances. Be sure to verify those amounts.

- Most Medicare Advantage Plans have a 20% Co-insurance on Immunotherapy, Chemotherapy and Infusion services. These services usually involve very expensive drugs, and the Co-insurance can add up quickly.