Nicholas Depke, Medicare Insurance Broker

Answer: The most common reason is that a higher premium plan may place your specific medications on lower cost tiers, meaning your overall annual spending including premiums and drug costs is actually less than a cheaper premium plan that covers your medications poorly. Another reason is pharmacy access, because some plans have preferred pharmacy networks where your costs are significantly lower, and if your preferred pharmacy is in that network a slightly higher premium plan could save you money overall. Formulary stability is also a factor, as some plans have a track record of keeping medications covered consistently year over year rather than making frequent formulary changes. The only way to know which plan truly costs you the least is to run a full comparison using your complete medication list that accounts for premiums, deductibles, copays, and pharmacy selection together, rather than choosing based on the monthly premium alone.

Answer: There is no Medicare rule or age cutoff that prevents someone from getting a CT scan at 78 or any other age. Medicare covers medically necessary diagnostic imaging including CT scans regardless of your age, as long as your doctor orders it for a legitimate medical reason and the service is performed by a Medicare participating provider. It is possible this misconception stems from a situation where a specific Medicare Advantage plan denied a prior authorization request, or where a doctor made a clinical judgment that a particular scan was not necessary, but neither of those scenarios reflects a Medicare age restriction. If you or someone you know has been told they cannot get a CT scan covered because of their age, that deserves a closer look and potentially an appeal. Denials can be challenged, and a Medicare agent or SHIP counselor can help you understand your rights and navigate that process.

Answer: Traditional Medicare does not cover home modifications like stairlifts, grab bars, wheelchair ramps, or other safety improvements, as these are considered home improvement expenses rather than medical services. However, some Medicare Advantage plans have expanded their supplemental benefits in recent years to include limited home modification allowances, particularly for members with chronic conditions or functional limitations, so it is worth checking your specific plan's benefits if you are on Medicare Advantage. Medicaid, if you qualify, has waiver programs in many states that can cover home modifications for low income seniors who need them to remain safely at home. Veterans may also have access to home modification grants through the VA that are worth exploring. If cost is a concern there are also nonprofit organizations and state aging programs that offer assistance with home safety modifications, and your local Area Agency on Aging is a good starting point to find out what resources are available in your area.

Answer: Medicare Advantage plans are approved and offered on a county by county basis, meaning the plans available to you depend entirely on where you live. Someone in a major metropolitan area may have dozens of plan options to choose from, while someone in a rural county may have very few or in some cases none at all. This also means that if you move to a different county or state you trigger a Special Enrollment Period and need to find a new plan, because your current Medicare Advantage plan likely will not follow you to your new address. Plan benefits, premiums, and networks can vary significantly from one county to the next even within the same state and with the same carrier. If you are considering relocating, it is worth researching what Medicare Advantage options are available in your destination area before you move so you are not caught off guard by a limited selection or a plan that does not meet your needs.

Answer: Medicare's plan finder tool at medicare.gov allows you to enter all of your prescriptions and compare what each plan would cost you for the full year including premiums, deductibles, and cost sharing, not just the monthly premium. An independent agent can also run this comparison for you and often knows the nuances of which plans have more favorable formularies for specific drug categories. Pay attention to which tier your medications fall on, whether any require prior authorization or step therapy, and whether your preferred pharmacy is in the plan's network since costs can vary significantly between retail and preferred pharmacies. With the new $2,000 out-of-pocket cap in place for 2025, high cost medication users have more protection than ever, but getting on the right plan upfront still makes a big difference in what you pay throughout the year.

Answer: You can apply to change your Medigap plan at any time, but outside of protected enrollment windows you will have to go through medical underwriting, meaning carriers can charge you more or deny you based on your health history. The best time to enroll is during your six month Initial Enrollment Period when you first get Part B, because during that window no one can deny you or charge you extra due to pre-existing conditions. Some states have more favorable rules than others, and certain life events like losing employer coverage can trigger guaranteed issue rights outside of that initial window. If you are considering a switch, talk to an independent agent first so you fully understand your options and rights before you apply.

Answer: One of the most underrated benefits of Original Medicare is the freedom to see any doctor, specialist, or hospital in the country that accepts Medicare without needing a referral or worrying about network restrictions. Most people do not fully appreciate this until they need a second opinion from a specialist at a major medical center like Mayo Clinic or Cleveland Clinic, and they can simply go without asking anyone's permission. Another overlooked benefit is the Welcome to Medicare preventive visit and the annual wellness visit, which are covered at no cost and give you a dedicated opportunity to build a health plan with your doctor each year. Original Medicare also gives you a level of stability that Advantage plans cannot always match, because your coverage does not change based on a carrier's annual network or formulary decisions. For people with serious or complex health conditions, that consistency and freedom of access can be worth far more than any extra benefit an Advantage plan advertises.

Answer: If you travel domestically, Original Medicare with a Medigap policy is hard to beat because it works with any doctor or hospital in the country that accepts Medicare, giving you true nationwide access without network restrictions. Medicare Advantage plans are network based, which means if you travel outside your plan's service area you are generally only covered for emergency or urgent care, not routine services. For international travel, Original Medicare provides virtually no coverage outside the United States, so your Medigap plan becomes especially important. Plans G and N both include a foreign travel emergency benefit that covers 80 percent of emergency care costs outside the US after a small deductible, up to a lifetime maximum of $50,000. If you travel internationally often or for extended periods, a standalone travel insurance policy on top of your Medigap coverage is worth considering for added protection. The bottom line is that frequent travelers are usually best served by Original Medicare paired with a strong Medigap policy rather than a Medicare Advantage plan.

Answer: For most seniors Plan G offers the best overall value because it covers nearly everything Original Medicare does not, including the Part B coinsurance, skilled nursing facility coinsurance, and foreign travel emergency coverage, with the only out of pocket exposure being the annual Part B deductible which is $257 in 2025. Plan N is worth considering for healthier seniors who want a lower monthly premium and are comfortable with small office visit copays and potential exposure to excess charges. Plan G gives you the most predictable cost structure of any plan currently available to new Medicare enrollees, which is why it has become the most popular Medigap option. That said, the best value depends on your health, how often you use your coverage, and what you can comfortably afford in monthly premiums. An independent agent can run a side by side comparison of premiums from multiple carriers so you are not overpaying for the same coverage.

Answer: If you cannot show proof of creditable coverage for a period when you were eligible for Medicare but did not enroll, you face permanent premium penalties that never go away. The Part B penalty adds 10 percent to your premium for every 12 months you went without coverage, and the Part D penalty is calculated on how long you went without creditable drug coverage and gets tacked onto your monthly premium for life. Not all insurance qualifies, so never assume your retiree coverage or other plan meets the standard without verifying it first. If you have a gap or are unsure where you stand, talk to a Medicare agent or your local SHIP counselor before your enrollment deadlines, because fixing this before you enroll is always easier than dealing with penalties after the fact.

Answer: Original Medicare does not cover routine eye exams for glasses or contacts, and that surprises a lot of people who assume Medicare covers everything vision related. However, Medicare Part B does cover medically necessary eye care, meaning if your doctor needs to examine your eyes in connection with a condition like glaucoma, macular degeneration, diabetic retinopathy, or cataracts, that is covered as a medical service rather than a routine vision benefit. For seniors who need nothing more than an annual exam to update their glasses prescription, that cost comes entirely out of pocket under Original Medicare. This is one area where Medicare Advantage plans can offer a real advantage, as most of them include some level of routine vision benefits such as an annual eye exam and an allowance toward glasses or contact lenses at no extra premium. Standalone vision insurance plans are also an option for people on Original Medicare who want to fill that gap. If vision care is important to you, and for most seniors it is, it is worth factoring the vision benefit into your plan comparison rather than treating it as an afterthought.

Answer: Unfortunately this is one of the most common frustrations we hear from Medicare Advantage enrollees, and it catches a lot of people off guard. Here is a response:

Dental benefits in Medicare Advantage plans are considered supplemental benefits, which means carriers have a lot of flexibility in how they design and limit them. What gets advertised as dental coverage often turns out to be limited to preventive services like cleanings and X-rays, with little to no coverage for major work like crowns, root canals, dentures, or implants. Some plans do offer more robust dental benefits, but they may come with annual dollar caps, waiting periods for major services, or require you to use a specific network of dentists. The marketing around these benefits has become increasingly aggressive in recent years, and regulators have taken notice, but the gap between what is advertised and what is actually covered remains a real problem. If your current plan's dental coverage is not meeting your needs, the Annual Enrollment Period each fall from October 15 through December 7 is your opportunity to shop for a plan with stronger dental benefits. There are also standalone dental insurance plans worth considering if you have significant dental needs that your Medicare Advantage plan is not addressing.

Answer: The $2,000 out-of-pocket cap on Medicare Part D drug costs that took effect in 2025 is one of the most significant improvements to Medicare drug coverage since Part D launched in 2006. Before this change there was effectively no ceiling on what a beneficiary could spend on prescriptions in a given year, which left people on high-cost specialty medications in a really difficult financial position. Now once you hit $2,000 in out-of-pocket drug costs your cost sharing drops to zero for the rest of the calendar year, making prescription costs far more predictable. The cap also pairs with the new Medicare Prescription Payment Plan, which lets you spread that potential out-of-pocket cost across monthly installments rather than absorbing large expenses early in the year. That said, premiums and formularies vary across plans, so running a plan comparison each fall during Annual Enrollment is the best way to make sure you are getting the most out of these new protections.

Answer: The good news is that if your MRI was ordered by your doctor for a medically necessary reason, Medicare Part B should cover 80 percent of the approved cost after you meet your annual Part B deductible, and that is where your Plan N comes in to cover most of the remaining 20 percent. Plan N is a strong Medigap policy but it does have a couple of cost sharing features worth knowing about. You may owe a copay of up to $20 for an office visit or up to $50 for an emergency room visit under Plan N, but those apply to the visit itself rather than the MRI specifically. One thing to watch for is something called excess charges, which occur when a provider does not accept Medicare assignment and bills above what Medicare approves. Plan N does not cover excess charges, so if your radiologist or imaging facility does not accept Medicare assignment you could owe the difference between what Medicare approved and what the provider billed, which can add up. The simplest way to protect yourself is to confirm that the facility where you had the MRI and the radiologist who read it both accept Medicare assignment, and if you are unsure your agent can help you think through your options or you can call Medicare directly at 1-800-MEDICARE to verify.

Answer: Retiring and moving from employer coverage to Medicare involves several moving parts, and the decisions you make in the first few months can affect your costs and coverage for years to come. The first thing to understand is that when your employer coverage ends due to retirement, you trigger a Special Enrollment Period that gives you eight months to sign up for Medicare Part B without facing a late enrollment penalty, but most people want to coordinate their start dates carefully so there is no gap in coverage. It is also important to know that COBRA does not count as qualifying coverage for purposes of delaying Medicare, so if you are considering COBRA as a bridge you need to be especially careful about how that interacts with your enrollment deadlines. Beyond the enrollment timing, you will want to think about whether Original Medicare with a Medigap policy and a Part D plan makes more sense for your situation, or whether a Medicare Advantage plan is a better fit, and that decision should factor in your doctors, your medications, your expected healthcare usage, and your budget. If your spouse is younger and still working, there may also be options worth exploring around their employer plan depending on how it coordinates with Medicare. People who have had good employer coverage for years are sometimes surprised by what Medicare does and does not cover, so sitting down with a knowledgeable agent before your retirement date rather than after is the smartest move you can make.

Answer: Great topic and one that affects a lot of Medicare beneficiaries in a meaningful way. Here is a response:

The Inflation Reduction Act brought some of the most significant changes to Medicare Part D drug coverage in the program's history, and the impacts are being felt in both 2025 and beyond. The biggest change that took effect in 2025 is the $2,000 out-of-pocket cap on Part D drug costs, which means once you have spent $2,000 on covered medications in a calendar year your cost sharing drops to zero for the rest of the year. This is a game changer for people on expensive specialty medications or multiple high-cost prescriptions who previously had no ceiling on what they could owe. Also in 2025, the catastrophic coverage phase no longer requires beneficiaries to pay coinsurance, and the coverage gap commonly known as the donut hole has been effectively eliminated. Another helpful feature is the Medicare Prescription Payment Plan, which allows beneficiaries to spread their out-of-pocket drug costs across monthly installments throughout the year rather than facing large lump sum payments early in the year when deductibles and initial cost sharing hit. For 2026 the core structure of these changes remains in place, but it is worth noting that many Part D plans responded to these reforms by adjusting their premiums, deductibles, and formularies, so the plan that worked best for you in 2025 may not be the most cost effective option in 2026. Reviewing your Part D coverage every single year during Annual Enrollment is more important now than ever.

Answer: Here is the updated response:

My go-to approach is to start with a simple education session before ever talking about specific products. I literally pull out a piece of paper and walk through the basics so the person in front of me can see exactly how Medicare works, what the gaps are, and why those gaps matter. When people can look at it visually and follow along, the whole thing starts to make a lot more sense. From there I assess their full picture, including their budget, their health situation, how often they use their coverage, and which doctors and medications matter most to them. Honestly, if someone can afford a Medigap policy, that is usually my first preference because the freedom, predictability, and access it provides are hard to beat, especially as people get older and start using their coverage more frequently. But the reality is that the monthly premium for a supplement plus a standalone Part D plan is out of reach for some people, and putting someone in a plan they cannot comfortably afford does not serve them well. In those cases, the goal shifts to finding the best possible Medicare Advantage plan for their specific needs, making sure their doctors are in network, their medications are covered, and their out-of-pocket exposure is manageable. There is no one size fits all answer, and anyone who tells you otherwise is not giving you the full picture. The best plan is the one that fits your life and your budget, and that looks different for everyone.

Answer: Yes, Medicare does cover antidepressants and anti-anxiety medications, and these actually fall into a protected drug class under Medicare Part D, which means plans are required to cover substantially all medications in that category. This is good news for beneficiaries who rely on these prescriptions because it offers stronger protections compared to other drug categories where plans have more flexibility to limit coverage. That said, the tier your specific medication falls on and your cost sharing can still vary quite a bit from plan to plan, so what you pay out of pocket depends on which Part D plan or Medicare Advantage plan you are enrolled in. Generic versions of these medications are often covered at very low cost sharing, while brand name options may sit on a higher tier with a larger copay or coinsurance. Also worth knowing is that starting in 2025, the $2,000 out-of-pocket cap on Part D drug costs provides an additional layer of protection if your medication costs run high. If you are concerned about what you are paying for a specific prescription, running a plan comparison during Annual Enrollment each fall is the best way to make sure you are on the most cost effective plan for your needs.

Answer: This is a really important question and one that catches a lot of people off guard. When you are already receiving Social Security benefits, Medicare enrollment happens automatically, but when you delay Social Security like you are planning to, you have to actively sign up for Medicare yourself or risk facing permanent late enrollment penalties. Your Initial Enrollment Period for Medicare is a seven month window that includes the three months before your 65th birthday, your birthday month, and the three months after, and you need to take action during that window to avoid penalties on Part B specifically. Part A is usually premium free for most people so that one is straightforward, but Part B carries a penalty of 10 percent added to your premium for every 12 month period you were eligible but did not enroll, and that penalty stays with you for life. The one exception is if you are still working at 65 and covered under a qualified employer group health plan, in which case you may be able to delay Part B without penalty until that coverage ends. Since you are approaching 65 soon, now is the time to get with a Medicare agent or contact Social Security directly to make sure your enrollment is handled correctly and on time.

Answer: Original Medicare is pretty limited when it comes to vision coverage, and this surprises a lot of people. It does not cover routine eye exams for glasses or contacts, and it does not pay for eyeglasses or contact lenses in most situations. Where Original Medicare does step in is for medically necessary eye care, such as treatment for glaucoma, macular degeneration, diabetic retinopathy, or cataract surgery, because those are considered medical conditions rather than routine vision needs. If you want broader vision coverage, Medicare Advantage plans are worth looking at because most of them include some level of routine vision benefits like annual eye exams and an allowance toward glasses or contacts as part of the plan at no extra premium. There are also standalone vision insurance plans available if you are on Original Medicare and want to fill that gap. It is one of the more common coverage surprises for people new to Medicare, so it is worth factoring into your plan decision.

Answer: Telehealth coverage under Medicare has been an evolving topic since it expanded significantly during the COVID-19 pandemic, and 2026 brings some important updates. Congress extended many of the telehealth flexibilities through the end of 2026, meaning Medicare beneficiaries can still access a wide range of telehealth services from their home rather than having to travel to an originating site like a rural clinic or hospital. This includes visits with doctors, mental health providers, and certain specialists conducted via video or phone. Medicare Advantage plans have generally been even more flexible with telehealth benefits than Original Medicare, so if you are on an Advantage plan it is worth reviewing your plan documents or calling your carrier to understand exactly what is covered. The telehealth landscape has shifted frequently in recent years, so checking with your agent or visiting medicare.gov for the most current guidelines is always a smart move.

Answer: Not necessarily, but it is absolutely worth checking. Every Part D drug plan and Medicare Advantage plan with drug coverage has its own formulary, which is the list of covered medications, and your new prescription may or may not be on your current plan's formulary at a tier you can afford. The best thing to do is run a formulary check on your current plan right away to see how your new medication is covered and what your cost sharing looks like. If your plan does not cover it well, you may qualify for a Special Enrollment Period depending on your situation, and the Annual Enrollment Period each fall from October 15 through December 7 is always an opportunity to switch to a plan that better covers your medications. Do not wait until the bills start adding up to take a look at this, because the difference in cost between a plan that covers your drug well and one that does not can be significant.

Answer: The three-midnight rule actually applies to Original Medicare, not Medicare Advantage, and it refers to the requirement that a patient must be formally admitted as an inpatient for at least three consecutive midnights before Medicare will cover a skilled nursing facility stay. This rule trips up a lot of Medicare beneficiaries because hospitals sometimes place patients under observation status rather than formally admitting them, and observation stays do not count toward the three-midnight threshold even if you are sleeping in a hospital bed for several nights. Medicare Advantage plans handle skilled nursing facility coverage differently depending on the plan, and many have their own criteria that do not follow the three-midnight rule at all, so it is important to understand how your specific plan works before you need that benefit. If you or a loved one is ever hospitalized, it is worth asking the hospital staff directly whether you are being admitted as an inpatient or placed under observation, because that distinction can have a significant impact on what you owe.

Answer: Medicare can absolutely feel overwhelming between Part A, Part B, Part C, Part D, Medigap lettered plans, enrollment windows, and income-based premiums, but the good news is you do not have to figure it out alone. A licensed independent Medicare agent is trained to cut through all of that confusion, explain your options in plain language, and match you with coverage that actually fits your life and budget. Best of all, working with an agent costs you nothing since they are compensated by the insurance carriers, not by you. There is also a free government program called SHIP, which stands for State Health Insurance Assistance Program, that provides unbiased Medicare counseling if you want a second opinion or just want to learn more before making any decisions.

Answer: It is a fair question, and the skepticism is understandable, but the extra benefits you see advertised with Medicare Advantage plans like grocery allowances, over-the-counter cards, and utility credits are actually funded by the government rebate dollars that carriers receive when they operate efficiently. That said, the marketing around these benefits has gotten aggressive and sometimes misleading, which is why CMS has cracked down on how carriers can advertise them. The most important thing to remember is that a flashy benefit should never be the main reason you choose a plan, because a $50 monthly grocery card means very little if the plan has a narrow network, high out-of-pocket maximums, or does not cover your medications well. Always look at the full picture of the plan before enrolling.

Answer: The honest answer is that neither one is universally better, because the right choice depends on your health, your finances, your doctors, and how you like to use your coverage. Medicare Advantage plans typically have lower monthly premiums and often include extra benefits like dental and vision, but they use provider networks and require prior authorizations. Medigap policies give you the freedom to see any doctor who accepts Medicare with little to no cost sharing, but come with higher monthly premiums and require a separate Part D drug plan. An independent agent can walk you through both options side by side based on your specific situation so you can make a confident decision.

Answer: Some hospitals and health systems have been dropping Medicare Advantage plans or refusing to contract with certain carriers because the reimbursement rates insurers pay are often lower than what Medicare pays directly, and the prior authorization requirements have become a serious burden on their staff and patients. When a hospital spends significant time and resources fighting insurance companies for approvals on procedures that should be straightforward, it affects their ability to operate efficiently and gets in the way of patient care. This does not mean all hospitals are leaving all Medicare Advantage plans, but it is a real and growing trend worth paying attention to. If you are on a Medicare Advantage plan or considering one, it is smart to verify every year that your preferred hospitals and specialists are still in network, because networks can change on January 1st even if you stay on the same plan.

Answer: Your friend is likely referring to the $2,000 out-of-pocket cap on Medicare Part D drug costs that took effect in 2025, which is one of the biggest changes to Medicare drug coverage in years. Whether it helps you depends on what medications you take and what you currently spend on them, but if you have high-cost prescriptions, this cap means your drug costs stop at $2,000 for the year no matter what. The best way to find out if you would benefit is to have an agent run a plan comparison using your specific medication list, because the right Part D plan combined with the new cap could save you a significant amount of money compared to what you may have been paying before.

Answer: Working with a Medicare agent costs you nothing out of pocket since agents are paid by the insurance carriers, so you get expert guidance at no charge. A good agent will compare plans across multiple carriers, explain your options in plain language, and help you avoid costly mistakes like missing enrollment windows or picking a plan that does not cover your doctors or medications. Beyond the initial enrollment, your agent stays in your corner year after year, reviewing your coverage during Annual Enrollment and stepping in to help if you ever have a billing issue or claim dispute.