Michael Wehner, Medicare Insurance Agent

Answer: Nothing actually happens if you delay Medicare Part A enrollment because you are still on your spouse's employer plan. However, in most situations it makes sense to go ahead and enroll in Your Medicare Part A even though you have employer group coverage. Medicare Part A has no monthly premium and would be coordinated with your group coverage. The exception to that would be if you are still contributing to an HSA account. You can no longer do that once you have enrolled in Medicare. If you decide to enroll in your part A at a later date keep in mind Medicare will typically backdate your Part A start date by 6 months.

Answer: I understand that Medicare can be quite confusing. There are a couple of resources that can help you understand the Medicare "maze and alphabet soup". You can always reach out to a certified Medicare agent or broker. Licensed and certified agents are versed in all of your Medicare options and in educating you and helping you sort through the "maze". Another resource is SHIP which is the State Health Insurance Assistance Program who are available in all states. They are able to provide you with objective education on how Medicare works.

Answer: Regular Medicare isn't necessarily "better" than an Advantage plan. They are just different. Original Medicare (Parts A and B) allow you to see any provider that accepts Medicare. However, original Medicare has limits on the number of lifetime days you can stay in the hospital and only covers 80% of you Part B services (Outpatient) with no out of pocket limit. Original Medicare also doesn't include Prescription Drug coverage (Part D). Medicare Advantage covers all of the things that Original Medicare Covers but provides an out of pocket maximum. Also most Medicare Advantage plans will also include your drug coverage as part of the plan. Many Advantage plans will also include things like dental and vision that Original Medicare does not. Most advantage plans do work with networks of providers so it is important to make sure that your providers are in network with the plan.

Answer: So the question is, my friend told me I should just go with the cheapest Medicare plan. That sounds too simple. What am I missing? I believe you're missing a couple of things. One is, if you're looking at Medicare Advantage plans, those plans typically work with networks of providers. So you want to make sure that the doctors and hospitals you see are included in the network of that plan. Or you could be in a situation where those doctors or hospitals might not be covered.

Additionally, all of the Medicare Advantage plans have different formularies and cover prescription drugs differently. So based on the prescription drugs that you happen to take, one Advantage plan might not work at all for you, while another one will, just based on those two things.

So first and foremost, if you're looking at Medicare Advantage, you really want to make sure doctors and hospitals are in-network and that it's doing the best job of covering your prescription drugs. On the other hand, if you are looking at Medicare supplement plans, or what people call Medigap, those plans are standardized. So the same plan works the same way from company to company. There's not variance in what the benefits are or how they are covered.

In that case, many times choosing the least expensive Medicare supplement plan might work best. On the prescription drug side of things, though, when you then look at prescription drug plans, again, you want to make sure that the drugs you happen to take fit in the formulary of the prescription drug plan that you're choosing. And that it's offering the best value for you.

Answer: The question is, how can insurance companies afford to offer Advantage plans with $0 monthly premiums? That's a great question. So the way Medicare Advantage actually works is when something happens to you, Medicare, instead of paying out part of the claim, they're actually paying a private insurance company to administer all of your benefits in one program, many times including your prescription drugs.

The reason that the premiums are $0 is because Medicare is reimbursing that insurance company enough money that they can provide the benefits to you without charging you additional premium.

Answer: That depends. If you are on Medicare Part A only or not on Medicare at all because of having employer group coverage, you will need to sign up for Medicare so that you have both Part A and Part B. Once you have your Part A and Part B, you will be able to look at options to help cover what Medicare does not.

Answer: If you are on Social Security Disability and are under 65, you will qualify automatically for Medicare after 24 months of being on disability.

Answer: Each Medicare Advantage Carrier has an online provider search tool where you can verify if doctors are in network with that plan. The online tool is the most accurate and up to date way to confirm that providers are in network. The easiest way to find the online provider search tool would be to do a google search for the name of the carrier provider search.

Answer: If you changed your plan during the Annual Election period which runs from October 15 to December 7 each year and have a Medicare Advantage plan, you also have an Open Enrollment period that runs from January 1 to March 31 to make a one time change to your Medicare Advantage plan. You can either switch to a different Medicare Advantage plan or drop your Medicare Advantage plan and return to Original Medicare and choose a Stand Alone Drug plan (Part D). If you changed your plan in the Open Enrollment period (January 1 to March 31) and the plan you switched to has not taken effect, you may be able to contact the carrier and withdraw the application. This will allow you to then use your Open Enrollment opportunity to switch to a plan that accepts your specialist.

Answer: No, you will not owe a penalty. Because you have creditable employer coverage, you can delay your enrollment in Part B until the time that you are going to go off of the employer group plan.

Answer: In most cases, the answer is no. To switch from a Medicare Advantage plan to a Medicare Supplement/Medigap plan you most likely will have to answer health questions to qualify for the Medicare Supplement plan. There are a couple of exceptions to this. The first is that if you chose a Medicare Advantage plan when you first turned 65 and have had it for less than 12 months, you have a 12 month trial period for the Medicare Advantage plan and can switch to a Medicare Supplement plan without having to answer the health questions. You also have the same 12 month trial right if you started on a Medicare Supplement plan and switched to a Medicare Advantage plan for the first time. The only other way to be able to switch to a Medicare Supplement plan without having to answer health questions is if the Medicare Advantage plan is leaving your coverage area. In that case, you would also be able to switch to a Medicare Supplement plan without having to answer health questions.

Answer: The question is, I want to switch to Medicare Advantage this year. How do I do this? Actually, the process is pretty simple. The annual election period runs from October 15th through December 7th, and during that time, you should be able to switch to a Medicare Advantage plan.

A couple of things to keep in mind if you've been on original Medicare or a Medicare supplement plan is you've probably been used to being able to see virtually any doctor and not have a network of providers. Just keep in mind most Medicare Advantage plans will have networks of providers. So you just want to make sure that the plans that you're looking at include your doctors and hospital in the plan.

One other thing to keep in mind is each of those plans have different formularies and cover prescription drugs differently. So the second thing that you would want to do is make sure that the prescriptions you take also line up with the Medicare Advantage plan that you choose.

For me, the easiest way to do that is to find a local agent who is versed in how Medicare Advantage works. To assist you in making sure that you find a plan that includes both your doctors and hospitals as well as your prescriptions.

Answer: The question is, I just enrolled in Medicare and I've got my Part A and Part B, but I'm hearing there are gaps in coverage. What are these gaps exactly?

So, your original Medicare, which is your Part A and Part B, does not cover everything. Part A is primarily for hospital services, and Part B is primarily for your outpatient services. So, what does that not cover?

First of all, your Part A and Part B do not address prescription drugs. You would address prescription drugs by purchasing a separate standalone drug plan, often called Part D, or a Medicare Advantage plan that includes prescription drugs. That's referred to as Part C.

In addition, your Part B, which covers your outpatient services, only covers those things at 80%, with no out-of-pocket limit. And then, on your Part A for hospitalization, you have a deductible that you have to meet. Your Part A also limits the number of lifetime days that you can ultimately stay in the hospital.

So, someone who just has their original Medicare, their Part A and their Part B, realistically has unlimited out-of-pocket exposure without purchasing additional coverage, such as a Medicare Advantage plan or a Medicare supplement plan with a prescription drug plan. Hopefully, that answers your question.

Answer: There is really no frustration in the enrollment process unless technology doesn't work correctly. We are able to help clients understand their options and advise on what best fits their situation. The only occasional hiccup is when something breaks down in technology in completing an application. The good news is we have different pathways that allow us to make sure that the client's needs are taken care of.

Answer: The question is, what do I enjoy most about working with Medicare clients? For me, that's an easy one. For most people, Medicare is very confusing. You get bombarded with mail, all kinds of information that crisscrosses and doesn't make sense. The joy of helping people with Medicare is helping them sort through all of that mess and really understand in simple terms what their Medicare options are, what the potential pros and cons of each of those options are, and then truly helping them zero in on what best fits their circumstance, their situation. So for me, it's educating people and helping make Medicare simple for them.

Answer: Medicare Advantage plans are not allowed to offer any kind of inducements to get someone to enroll in a plan. If you are being offered some sort of inducement to enroll in a plan, that is not the Medicare Advantage plan offering that, but someone who is not acting ethically.

Answer: All Part D plans work from formularies (a list of the drugs that that plan covers). The formularies are different from plan to plan. All part D plans must provide at least one medication in each therapeutic class but are not required to cover every drug. So a Part D plan can deny coverage for a specific drug. If you are in that situation and that particular drug is what you need, your doctor can file for a drug exception to see if the plan will cover that drug even though it is not on their regular formulary.

Answer: Medicare certainly can be overwhelming. Finding a trusted agent who understands the differences in your choices is to me a very important thing to do. If you needed to have your appendix out, it wouldn't make sense to try to figure out how to do that on your own--you would find an expert--a doctor who could take care of that. Same thing is true here. There are agents who are well versed in all of those options who can help you zero in on the plan that best fits your needs and circumstances.

Answer: Medicare can be quite confusing. It is important to know the differences between your options and to know the potential pros and cons of those choices. My advice is to always seek a trusted advisor or agent who understands how Medicare works and what those options are. All of our needs are different and what might be a good fit for one person, may be a bad choice for someone else.

Answer: With Employer group plans, Medicare coordinates benefits. But it depends on what size of employer group you are a part of. If your group is larger than 20 employees, your group plan will be primary and Medicare will be secondary. Many Medicare beneficiaries delay their Part B coverage and only opt for Part A when they are part of a group plan that has more than 20 employees. If your are part of an Employer group that is less than 20 employees, Medicare will be primary and the group plan will be secondary. It will be important for you to enroll in both Part A and B is you are on a small employer group plan. Also, if you are on a small employer group plan (under 20 employees) that plan may choose to not allow you to continue that coverage once you are enrolled in Medicare.

Veterans Affairs benefits typically work separately from your Medicare Coverage. But having additional Medicare coverage such as a Medicare Advantage plan allows you to receive care outside of the VA system if you so choose.

Answer: Not necessarily. It is important to review your summary of benefits and associated co pays with the different plans that you are deciding between. Most Medicare Advantage plans have a $0 co pay for primary care visits and preventive care. Specialist co pays vary from plan to plan.

Answer: Yes, some Medicare Advantage plans do cover acupuncture and some other alternative care therapies such as routine chiropractic care. You should review your Evidence of Coverage document to see if such things are covered on your plan. Everything that the plan covers is documented in the Evidence of Coverage.

Answer: Medicare can be confusing for many people. The best way in my opinion to discuss Medicare with your parents is to involve a trusted Medicare agent who understands how Medicare works.

Answer: Outpatient Surgery is covered by Medicare Part B. This means that after your part B deductible, you are responsible for 20% of the costs associated with your surgery with no out of pocket limit. If you have a Medicare Advantage plan you will typically have a fixed co pay for an outpatient surgery or a cost sharing percentage, but only up to your plan's maximum out of pocket. If you are on a Medicare Supplement plan, your supplement plan will pick up some or all of the remaining 20% depending on which Medicare Supplement plan you are on.

Answer: If you are on a Medicare Advantage plan or a PDP-Prescription Drug Plan, every year (usually in September) you will receive an Annual Notice of Change document (ANOC) from your insurance company. This document highlights all the things that are changing in your plan. If you are on Original Medicare or on a Medicare Supplement plan, those plans are standardized and typically do not change from year to year.

Answer: Original Medicare, which consists of Part A (Hospital) and Part B Medical, Outpatient) does not cover everything and does not address prescription drug coverage. Original Medicare covers 80% of outpatient services with no out of pocket limit and limits the number of lifetime days in the hospital. Medicare Advantage is one of the options that people choose to help cover things that Original Medicare does not. Medicare Advantage plans cover everything that is included in Original Medicare and many times covers additional things. You can get Medicare Advantage plans that include prescription drugs. Also, Medicare Advantage plans will have a maximum out of pocket for medical expenses that doesn't exist with Original Medicare. Many Medicare Advantage plans will also include extra benefits like dental, vision and hearing as well as Over the Counter items (vitamins and basic medical supplies).

Answer: Original Medicare which consists of Part A and B only covers 80% of part B (outpatient services) with no out of pocket limit. It also has a limit on the number of lifetime days you will be covered in the hospital. Additionally, original Medicare does not address prescription drug costs unless you purchase separate drug coverage (Part D). You can choose to purchase a Medicare Advantage plan (Part C) that includes prescription drug coverage or purchase a Medicare Supplement plan along with a separate stand alone drug plan to help cover what Original Medicare does not.

Answer: Medicare can not drop you for health reasons. Neither can a Medicare plan drop you because you've developed any kind of health issues.