Rich Baker, Medicare Insurance Broker

Answer: There are typically Medicare Advantage plans in your area that include some level of dental and vision coverage. Medicare.gov, or an agent, can help you find one that gives you the most benefit. Medigap plans (and original Medicare by itself) do NOT cover most dental and vision issues.

Note that as costs rise, many Medicare Advantage carriers are pulling back on some of these benefits. In my local area there are several that only cover preventive dental (cleanings and X-rays) and any comprehensive work is paid out of pocket.

As a result more seniors are choosing to add a standalone dental and/or vision plan. These plans operate separately from Medicare and changes to medicare coverage do not affect them.

Before you make any changes to your coverage, it’s a good idea to consult with a broker (or medicare.gov) to assess what will meet your needs.

Answer: You’re covered for emergency and urgent care anywhere in the United States at your plan’s copays. Going on a trip across the country, this is what most people are concerned with. In or out of network, your plan covers you nationwide for emergencies and urgent care.

Some HMOs have a travel benefit where you can see a doctor for a non-emergent issue as long as that doctor is in their nationwide network. Outside of the network, you’ll pay full price.

PPOs will generally allow you see a doctor in a different state (in or out of network) for non-emergent issues, albeit generally at a higher copay than in your home region. People who spend much of the year in a different state (primary residence in Michigan, winter home in Arizona, for example) will choose a PPO for just that reason since they may be in one place long enough to need to see a doctor outside of an emergency setting.

Check your Summary Of Benefits or Evidence Of Coverage document (usually available on your provider’s website) for the details about your specific plan, or ask your agent to help you work through those details.

Answer: With few exceptions, your part D plan can only be changed during the Annual Enrollment Period (AEP).

There are a few special election periods, like if you move to a new service area with new plan options, for example, but you would have to meet special criteria for each of them. An agent can help you see if you qualify for any of them.

Answer: You can, but it typically doesn’t make sense. Once you have Medicare Part A you lose all tax subsidies and would pay the full marketplace premium.

In general, a better option would be to pair your medicare with a Medigap plan or a Medicare Advantage plan.

Answer: Yes, unlike Medicare Advantage, Medicare Supplement plan changes are not limited to two and a half months from October to December each year. HOWEVER - unless you have a guaranteed issue window, you will have to undergo medical underwriting if you don’t have a guaranteed issue window available to you.

Answer: My short answer would be the limitations around the doctor networks. More providers are going to HMOs, which can limit the doctors you see. Even with a PPO, and out-of-network doctor doesn’t HAVE to see you. And a provider network may chose not to accept any plans from a specific insurer. Having said that, I am usually able to find a plan that works for my client’s needs, which is why I work with almost every insurance provider in my area.

Also depending on the plan, the Maximum Out Of Pocket (MOOP) can be pretty high. This generally only matters if you have really bad medical year and end up in the hospital several times (and have to pay those per-day copays each time) or have something like Chemotherapy which incurs a 20% coinsurance.

However, there are hospital indemnity plans available that can pay you back for those hospital copays, and cancer riders that can help cover the MOOP.

So, there are additional products that can help you creatively reduce some of those risks.

I’ll answer a question you DIDN’T ask - and list some of the advantages of a Medicare Advantage plan:

- USUALLY (not always) have no premium. If you’re healthy, you can save a lot of money vs. a Medigap plan. For some people this is very important.

- USUALLY include some level of dental, vision, and hearing coverage. Medigap does not.

- USUALLY include your part D coverage. Medigap does not, though some providers offer discount programs.

- SOMETIMES include things like non-emergency transportation, over-the-counter stipends, or healthy benefits cards (if you qualify, these cards can be used to purchase food). Medigap does not.

- USUALLY include a program that gives a health club membership or workout at home option. Some medigap plans also offer this benefit.

There are plusses and minuses with both pathways for your supplemental medicare coverage (Medigap vs Medicare Advantage). A good agent will talk through your needs and help you select a plan that most closely matches those needs.

Answer: Believe it or not there are a lot limitations as to what I, as an independent agent, am allowed to put in an ad. So in general, no I don’t think there needs to be more regulation.

I used to work for a large brokerage which ran ads on TV saying something to the effect of “if you have medicare, you may qualify for a debit card that gives you up to $200 per month for food” and people would call in wanting that debit card. They never saw the fine print that says it was only certain plans and that you had to qualify for that benefit, and if you DID qualify, you’d have to switch plans. It was left up to me, the agent who answers the phone, to have that conversation - which often did not go well.

So, in my opinion, ads like that are a bit sketchy. If every drug ad has to list the possible side effects of the drug, medicare ads that speak about a popular but not universal benefit should have to provide that clarity.

BUT - that’s just my opinion. 😉

Answer: The qualified answer is it depends.

- is their employer coverage considered creditable? If not, enroll in Medicare to avoid late enrollment penalties.

- is their spousal coverage dependent on their keeping theirs? If yes, defer Medicare (at least part B) until their spouse qualifies for other coverage.

- How much does their employer coverage cost? If it’s less than the Part B premium, defer part B until ready to retire.

- Are they contributing to an HSA? If they’re contributing to an HSA they should defer part A because the IRS rules will disallow any contributions made after enrollment in Part A, causing tax issues.

If they’re not contributing to an HSA they can get Medicare Part A (hospitalization) if they qualify for premium free Part A (most people do). If the employer has more than 20 employees, the employer plan pays first and medicare may pay some of the remaining costs.

If the employer has less than 20 employees, Medicare pays hospital costs first and the employer plan pays second.

So this is a long way to say ‘it depends’ but there are a lot of moving pieces to consider so I can’t just give a yes or no answer.

Answer: You’ll have a part B deductible of $283 (for 2026), then everything else should be covered for the remainder of the year.

With plan N, however, Medicare excess charges are not covered. So if your state allows them (not every state does) you could be responsible for those too. Excess charges occur when a doctor or facility takes medicare patients but doesn’t accept medicare assignment.

For example, just using simple numbers, if the facility hasn’t accepted medicare assignment, and charges $1,000, but medicare only pays $800, with plan N you would have to pay the remaining $200.

Plan G covers excess charges. This is generally why plan N has a lower premium than plan G. If your state doesn’t allow excess charges (Connecticut, Massachusetts, Minnesota, New York, Ohio, Pennsylvania, Rhode Island, and Vermont are the eight that do not) or the facility or doctor have accepted medicare assignment, you shouldn’t have any surprise bills.

Answer: I think there are layers to this question.

In general, unless it’s a part B medication (generally something that has to be administered in the doctor’s office) medicare does NOT cover medications.

Your Medicare Advantage plan, or your Part D plan, will be what covers your standard prescriptions. You can go to the provider’s website and they should have a tool that lets you enter your medications and will tell you if they cover them. Or, you can just call the number on the back of your card and customer support can help you.

If you use the website, be sure to pick the right format - often a provider will cover the tablet version of a drug, but not the capsule, for example, so that can cause confusion.

You can also contact your agent who can look it up for you. They should be happy to do so, especially if there’s been a change.

Answer: This is a great question, and the answer lies in how the agent works with you and what their priorities are. They should be paying attention to what is important to you, and if they don’t ask the right questions, don’t be afraid to tell them what matters most to you.

Do you want the lowest possible specialist copays? Or the most generous dental coverage? Those benefits typically will not exist on the same plan. Do you want a plan that gives you a credit back on your part B premium? You’ll very likely have higher copays.

What medications do you take? Some providers may not cover them all, or may have a lower (or no) deductible for Tier 3 and up medications.

Some agents may not be appointed with ALL providers in your area, so they can’t even talk to you about plans from their unappointed providers, while other agents may have a larger set of plans to offer. There’s a medicare required disclaimer every agent should read to you that tells you how many providers they work with and how many plans they offer.

Finally, how the agent gets paid can make a difference. In my area there’s really not a difference in the commissions that the provider pays me, and I’ve never taken that into consideration when recommending a plan. Some pay it all up front, some pay half up front and the other half throughout the year. It doesn’t really matter to me. I want a client who is happy with their coverage and wants to continue working with me. It makes no sense to sacrifice that long term relationship for a short term financial gain (if there is one). But, that’s me. Others may operate differently.

The net is that you should work with an agent you trust. One who digs into what your needs are, who explains WHY they’re recommending a plan, is up front about the providers they work with, and answers your questions fully and to your satisfaction. You should never sign up for a plan you don’t fully understand or have questions about.

Answer: In my experience the most confusing thing are the ads on TV that talk about a “food card.” There have been various permutations of this ad over the last few years, but the crux of them is a statement that you may be eligible for a monthly debit card of $100, $200, or more, to be used for the purchase of healthy foods.

I say this is confusing rather than misleading because those benefits DO exist - but only for certain people, and that’s often buried in the fine print. Also, people can tend to hear what they want to hear from a TV ad which makes the confusion worse.

The benefit is known as SSBCI - Special Supplemental Benefits for the Chronically Ill, and there are several different versions of it.

If you have medicare AND Medicaid, AND your Medicaid is the right level, you likely have access to plans that offer you a healthy benefits card. The amount on that card will vary based on your level of Medicaid and what service area you’re in. If you don’t have a Chronic Illness (CI), you can only use the card for over the counter products. If you DO have a CI, you can use it for food, utilities, even rent and transportation depending on the provider.

What if you don’t have Medicaid? There are still options available, though they don’t typically offer as much. If you have diabetes or a heart condition, there are many Chronic Special Needs Plans (CSNPs) that have a similar benefit. Generally, if you qualify for the CSNP, you’ll qualify for the SSBCI.

If you don’t have either of those conditions, but have high blood pressure, high cholesterol, certain lung conditions, or other chronic illnesses (there are several that vary by provider) you may be eligible for a plan with SSBCI included.

I personally don’t try to lure people in with a promise of these benefits. They may not qualify, and the plans often have higher copays and coinsurances than a plan without SSBCI included, but I’m happy to go over them if they match my client’s needs.

Answer: Medicare itself does not. If you have medicare advantage, many providers offer incentives and rewards for healthy activities, such as gift cards, over-the-counter credits and more. Each carrier’s program, if they have one, will be different from the others.

Contact the number on the back of your card or go to their website for more details.

Answer: In general, no. Your Medigap coverage is portable - in other words, plan G is plan G no matter where you go. The rates in Florida may be lower, so it might be worth going through underwriting to get a better rate.

I’d start by calling your carrier and telling them about your move, make sure they’re licensed in Florida, and see if they change your rate because of the move. You can decide what to do from there.

You WILL need to find a new Part D plan. You have the month of your move and the two months after to make that change, so don’t wait!

You can always reach out to a local agent if you need help. Good luck!!

Answer: This is impossible to answer! Some people get a tremendous amount of benefit from them and some don’t. Some have done a lot of research or grasp the nuances more easily and some people need a lot of interaction. So are they actually helpful? It depends who you ask.

It sounds like you’re fairly on top of things. I’m assuming this was an education session, not a marketing event. An education session by rule has to be pretty vague. Agents are not allowed to discuss plan details or specific benefits or it crosses the line into sales and marketing, which from a compliance perspective is a whole different thing.

If you were looking for that deeper level of detail, you won’t get it from a generic education session. You need to attend a marketing event, or schedule a session with an agent where they can get into that kind of detail. When I do an education seminar, I always invite people to reach out with any questions they still have or may come up with afterwards.

Hope this helps!

Answer: There are a LOT of moving parts to this question. For the sake of simplicity I am assuming you’re saying you missed the 7 month window (3 months before your birth month, your month of birth, and 3 months after) to sign up for Medicare.

You can call Social Security anytime to sign up for Part A as long you qualify for premium-free Part A (you’ve worked and paid into the system for at least 40 quarters, or 10 years).

For Part B, there’s a General Enrollment Period (GEP) from January 1st to March 31st each year, with Part B starting July 1st. If you were eligible this year, and signed up in GEP 2027, you will pay a 10% monthly penalty ($20.25 at the 2026 rate) per year you missed. It’s cumulative, so if you didn’t sign up until GEP 2028, you’d pay 20%, etc. It’s also permanent, so you pay that penalty as long as you have Part B coverage.

If you don’t qualify for premium free Part A, the same GEP applies, and the 10% penalty applies, but it only lasts for twice as long as you went without coverage. So the part A penalty is finite, the Part B penalty follows you forever.

However, if you have employer coverage or spousal coverage that can be considered creditable (VA coverage, COBRA, and ACA coverage are not creditable) then you have a different situation.

Your best bet is to talk to agent to review your situation in detail to see if any special election periods apply that can help you.

Answer: In general, the Inflation Reduction Act has helped people with expensive medications by getting rid of the coverage gap, or ‘donut hole’ and putting a cap on your Maximum Out Of Pocket (MOOP) costs at $2100 for 2026 and it’s looking like $2400 for 2027.

So depending on what you were paying under the old system, this may or may not help you. Without knowing the specific medication and cost, it’s hard to give a definitive answer, but again, in general it should help with higher cost meds.

You can always get in contact with an agent and review your specifics and they can give you a more detailed answer.

Answer: The devil is in the details here.

If you moved from a medigap plan to a medicare advantage (MAPD) for the FIRST TIME, you have a trial right to go back to your Medigap plan within the first 12 months, guaranteed issue. Often this is why a doctor would have been covered previously and not now since Medigap is accepted by all providers who accept Medicare, but MAPDs use specific provider networks. If you’ve had a MAPD previously, the trial right does not apply.

Since you mention Open Enrollment (OEP - which is January 1 - March 31) it sounds like you moved from one MAPD to another and your doctor isn’t in the new plan’s network. OEP is designed to address this situation, as many people make changes in Annual Enrollment (AEP) the previous fall, and once that plan goes into effect in the new year they find out they’re not happy with it. OEP gives them a do-over to either pick a new, different MA plan or go back to the old plan. If you made a change during OEP, in general, once the new plan goes into effect you’re in that plan until AEP in the fall. At that point you can switch to a plan your doctor DOES accept. This change would go into effect on January 1st next year.

You MAY qualify for other special election periods (SEP), so consulting a broker would be a good thing to do since they will know how to check eligibility for any SEPs. However, unfortunately, you most likely are in this plan through the end of the year.

Answer: Honestly some people just stay in a plan because they’re used to it, regardless of the cost in other plans.

In my experience people most often choose a higher cost plan because it covers their mix of medications better than the lower cost plans. A lower cost plan may not cover their insulin, for example, and they’re set on staying with that particular drug.

As a broker I always look at the options and if a client is going to hit the out of pocket maximum regardless, it makes sense to go with the lower premium plan as long as their medications are covered and they aren’t paying for them out of pocket.

Your broker should look at the options with you and help you find the plan that most fits your needs.

Answer: If the following conditions are met:

- a qualifying hospital stay of at least 3 days

- you need specialized care

- the reason for the SNF stay is the same as the hospital stay

The your medicare Part A (and Medigap and most Medicare Advantage Plans) cover the first 20 days in a Skilled Nursing Facility. Days 21-100 are $217 per day. Medigap Plan G covers this cost. Medicare Advantage plans can set their own copay schedule, but in general the follow the Part A copays. Under Medicare Advantage you pay the $217 per day (or whatever their copay schedule is) from day 21-100, or until you hit your Maximum Out Of Pocket Maximum, which ever comes first.

Once you hit day 101, Medicare no longer covers a SNF stay, so under original Medicare, Medicare + Medigap, or Medicare + Medicare Advantage, you pay 100% of the cost.

If your SNF rehab stay turns into Long Term (custodial) care, no matter what day this happens, Medicare no longer covers the cost of the stay, so neither will Medigap or Medicare Advantage. You will have to self-pay, pay with your Long Term Care Insurance, or if on Medicaid, Medicaid may pay.

I recommend talking to a broker about your situation to understand how your specific coverage will handle this situation.

Answer: You should talk to your benefits coordinator about when you can drop your coverage. In general, yes you can, but you will want to ensure you get the timing right. Losing employer coverage (or spousal coverage) triggers a special election period to get your Parts A & B started and get your supplemental coverage set up, but you want to so do it so you have no gaps in coverage.

If you are past your 65th birthday, you’ll also want to have a loss of coverage letter handy in case medicare asks for evidence you had creditable coverage in the intervening time frame.

You’ll also want to look at cost. Medicare Part B is $202.90 per month in 2026 and depending on which route you go for your supplemental coverage you could pay additional premiums of $200 or more. If your employer coverage costs less the part B Premium at a minimum, it might make more financial sense to keep your employer coverage until you’re ready to retire.

In any case, it’s worth talking to a broker to fully understand your situation and what options are available to you.

Answer: With Plan F your Part B deductible is paid by your provider so the only thing you need to pay is your monthly premium. Any emergency room charges will be covered as long as the provider accepts medicare.

Plan F is the most comprehensive Medigap plan you can have, but is only available to people who were Medicare eligible prior to January 2020.

Answer: Part A helps with hospital costs, but it’s not full coverage — there are deductibles, daily copays, and it doesn’t cover the doctors. Most people need additional coverage.

2026 Costs

• $1,732 deductible per benefit period (could be charged multiple times per year)

• $419/day for days 61–90

• $838/day for lifetime reserve days (days 91–150)

• After that you pay 100%

What Part A does NOT include at all

• Doctor services in the hospital (that’s Part B)

• Outpatient care

• ER visits (unless admitted)

• Follow-up care

For example, if you go to the hospital, you pay:

• The $1,732 deductible

• Surgeon, anesthesiologist, and radiologist bills. These are NOT covered by Part A

• Those fall under Part B (which has an 80/20 split). If you don’t have part B, you pay 100%.

So while Part A covers the hospital stay, not everything that happens during that stay is covered — and it still has large out-of-pocket costs.

This is why most people pair Part A with:

• Part B → covers doctors & outpatient care

• A Medigap (Plan G, etc.), which covers some deductibles & coinsurance

or

• A Medicare Advantage (MAPD) plan, which bundles everything together

There are significant differences in how Medigap and Medicare Advantage handle your Medicare benefits. An agent should be able to clearly explain them to you.

Answer: IMO, there are several reasons.

First, there’s going to be a premium for a MedSupp plan on top of your part B premium. I have many clients on a tight income and they can’t afford another $200+ per month for a supplement. There are alternatives like high deductible plans that have lower premiums, but many people feel that if they have a high deductible plan, they may as well get a Medicare Advantage plan, which, while it has copays, coinsurances, and provider networks, in many cases does not have a monthly premium.

Second, MedSupps require a separate Prescription Drug plan. In some cases, there are $0 premium plans available, but increasingly the PD standalone plans have premiums as well, so now you’ll have Medicare Part B, your MedSupp premium AND your part D plan premium. Most Medicare Advantage plans include Part D coverage, often at no additional premium.

Third, MedSupps do not provide dental, vision, or hearing coverage, so there are MORE premiums to add to the list. Most Medicare advantage plans include some level of DVH coverage.

Because of this, many brokers are reluctant to pitch a MedSupp. I personally will always ensure people, especially those new to Medicare, know their options so they can make an informed decision about their coverage that most fits their needs from a healthcare and budget perspective.

I hope this answers your question!

Answer: Most likely there’s a plan in your area that has some level of dental coverage. Some things to keep in mind:

- some areas do not have any plans with dental coverage, and the amount of coverage and copays will differ significantly, so you’ll need to so some comparison shopping (of course an agent will help with that, but you can also go to Medicare.gov)

- we’ve had a few tough years, cost-wise, so many plans are pulling back on the ancillary coverage (Dental Vision and Hearing, or DVH). I personally don’t see that changing going into 2027. Still, many plans will cover cleanings even if they don’t provide comprehensive coeverage.

- You will need a valid election period to enroll in a MA plan. That usually means AEP from October 15-Dec 7 unless a special election period applies. Again, an agent can walk through some situations to see if that’s the case.

- You’ve (hopefully) got a Prescription Drug plan, and may be paying for it. If so, you may save money with an MAPD because it replaces the standalone drug plan and many have no premium. It depends on your service area as to what is available.

- if you go with an MAPD, your doctor selection will be limited to the plan’s network, or, if it’s a PPO, you’ll pay higher copays for doctors out of network.

- You can also pick up dental coverage separately and not change your medical coverage. Most agents have several options available for stand-alone dental coverage.

- if all you have is OM + a PD plan, you have some financial exposure since medicare has no out of pocket maximum, so I really do recommend either a Medigap plan or Medicare Advantage to help mitigate that risk.

I hope this helps!!

Answer: Your costs will be capped at $2100 in 2026, but if you have a high monthly cost early in the year you do have an option called the Medicare Prescription Payment Plan (MP3). The MP3 doesn’t reduce your drug cost, but it spreads it out.

For example, if you have a drug that will cause you to hit the $2100 limit in the first couple of months of the year, if you sign up at the start of the year, you would pay $175 per month through the end of the year. You’re still paying $2100, but not all at once. Obviously the earlier the better for this idea. Reach out to your plan’s customer care number for more information.

You can press your doctor for any alternative meds (generics or biosimilars) that are lower cost but still treat the same conditions. You can also ask about free samples, or if a higher dosage can be prescribed which you then split in half each day.

If you have limited income, you have some additional options;

1. Extra Help (details at https://www.ssa.gov/medicare/part-d-extra-help). Depending on your income, you can reduce or eliminate your copays and deductibles if you qualify.

2. Manufacturer assistance. Needymeds.org and RxAssist.org have directories you can use to find assistance programs. These are also normally income or needs based.

3. Many states have a State Pharmaceutical Assistance Program (SPAP) which can help you. If you qualify you may even get a Special Election Period to change your Part D plan too.

You can also look at discount card programs like GoodRX or RxSaver.

There are alternative pharmacies like CostCo, Mark Cuban’s Cost Plus Drugs, and I think even Amazon is developing an alternative pharmacy.

Lastly, you should always shop for coverage during annual enrollment. You may find a plan with a lower deductible, or a flat Tier 3 copay vs a percentage coinsurance. Your agent can help you with that process, or you can go to medicare.gov or the carrier’s website to compare costs.

Answer: Generally, as long as your charges are all medicare approved, once you pay your $283 part B deductible, you shouldn’t have to pay anything else for the remainder of the year.

Anything NOT covered by medicare - if you need custodial care in a skilled nursing facility (not covered) vs. inpatient rehabilitation (covered), for example, would be your responsibility.

But in most cases, once you’ve paid the deductible, you’re covered for the rest.

Answer: I tell my clients that while we can, most of the time, find plans with a zero dollar premium, all medicare advantage plans have copayments and coinsurances for most services on the back-end. Someone who is healthy and only sees their primary care doctor once a year can save money vs paying for a Medigap plan, but it’s a risk-reward decision. A few days in the hospital or an unexpected need for cancer infusions can change that equation very quickly.

I thoroughly cover the copays listed in the summary of benefits with each client so they know what the potential costs are for those most common services, and what the Maximum Out Of Pocket (MOOP) is so they know what their total potential financial exposure is.

There are other ways to mitigate some of the potential costs, like hospital indemnity plans to help cover the hospital co-pay, but I will never pitch a plan with no premium as ‘no cost.’

Answer: There are a couple of ways.

First, CMS (the government organization that runs Medicare) is negotiating the cost down for the 10 most expensive drugs, expecting cost decreases of 38%-79%. Additional drug costs will be negotiated every year through 2031.

Second, the donut hole was eliminated, simplifying the Part D cost schedule and for some people saving them money.

Third, it lowered the cap for Out Of Pocket (OOP) spending to $2100 in 2026. After an out of pocket spend of $2100, all covered medications have a $0 copay. For people with multiple high cost drugs this can be a major cost saver.

There are some drawbacks. We’ve seen the number of part D plans decrease over the last couple of years as carrier costs have increased, resulting in less choice. And many providers are moving to a 25% coinsurance for Tier 3 drugs (like Eliquis, etc) which means the cost could actually go up compared to previous years with a flat fixed copay for Tier 3 meds. And more plans have deductibles this year too, further adding to the OOP cost for beneficiaries.

Because carrier’s plans change every year and vary on what is covered on their formularies, what tier a drug is on in their formulary, and how their deductible and copay/coinsurance schedule works, you should review your part D coverage every year to ensure it’s still your preferred option. You can do this through the carrier’s website, at Medicare.gov, or my favorite, by working with an agent.

Answer: I recommend medicare advantage (MA) over original medicare (OM) because:

- MA plans have a maximum out of pocket limit on expenses, after which the plan pays all additional expenses through the end of the plan year (this amount varies by plan). OM does not have a limit of what you can be charged. You pay 20% of infinity.

- MA plans typically include some level of dental coverage, hearing coverage, and vision coverage. OM does not.

- Many costs in MA plans are lower than what you would pay under OM.

- Most MA plans cover unlimited days in the hospital after the copay period (usually the first 5-7 days) at no additional cost. OM charges $1732 upon admission per benefit period (this covers the first 60 days); $419 per day from days 61-90 and $858 per day for days 91-150. After day 150 you pay 100%. While unlikely to happen, an MA plan typically offers better protection for an extended hospital stay.

- MA plans often offer over the counter coverage for things like vitamins and other health related items

-MA plans often offer incentives for healthy behavior (PCP visits, immunizations, physical activity bonuses) aimed and improving overall health.

There are many other factors to consider, like medical networks, that could impact your decision making process. I recommend getting with an agent and going through your specific situation and seeing what your options are.

Answer: The most stress free way to have supplemental medicare coverage in my opinion is by signing up for a medigap plan (also called a medicare supplement). With Medigap, you have a fixed premium and depending on the plan you’re eligible for, you may have no additional costs (plan F) or just pay the part B deductible (plan G).

The downside is that many people find the medigap premiums to be too high, and they tend to go up every year as you age. You will also need a standalone part D plan for your prescription coverage.

Since you’re concerned about bills, I recommend reaching out to an agent and having them walk through your specific situation and seeing if cost-wise a medigap plan makes more sense. If so, you can apply at any time (medigap is not limited to Annual Enrollment). You cannot have a medigap plan AND a medicare advantage plan at the same time, so you must have an election period (like annual enrollment) available to drop your Medicare Advantage plan and add a Part D plan, so that limits your flexibility. Again, an agent can help you navigate that timing.

I hope this helps!

Answer: There’s no definitive answer, but in general the typical time is between 3-6 weeks. Allow 2-4 weeks for application processing (it’s faster if you apply in person or online) and about 2 weeks for the physical card to be delivered. Your number should be available online immediately after approval, and you don’t need your physical card to apply for your supplemental coverage. You just need the number (your agent will still verify eligibility in the system).

The fastest way to check status is through a my Social Security account:

(https://www.ssa.gov/myaccount) or by calling the SSA.

Answer: This is a big question with a LOT of variables.

First, there are two pathways for supplemental medicare coverage: a medigap plan, or a medicare advantage plan. Which option is right for you depends on a lot of factors. But in general:

Cost:

Medigap plans will always have a premium tied to them. What the premium is depends on several factors and on the plan you choose. A high deductible plan G will have a much lower premium than a standard plan G, for example.

Medicare advantage plans are USUALLY (but not always) premium free so there could be no additional cost beyond your part B Premium.

In both cases you must continue to pay your part B premium in addition to any plan premiums to remain eligible.

Value:

The value of a Medigap plan is flexibility. There are no networks, so if a doctor accepts medicare, they accept your medigap plan. What your copayments or coinsurance would be depends on the plan you select. For example, if you choose a standard plan G, you pay the Medicare Part B deductible ($283 in 2026) and the plan pays the rest of your medical expenses. The coverage is simple. You do need to pick up a standalone Medicare Part D plan for prescription drug coverage, and there is no preventive dental, vision or hearing coverage.

A medicare advantage plan will typically include your part D coverage, as well as basic dental, hearing and vision coverage. Often you will get some comprehensive dental, a copay or stipend for hearing aids, and a stipend for eyewear. You will have a medical network (an HMO or PPO) which means you have to work with doctors in that network, and while there’s typically no premium, you will have copays for most services and those will vary by carrier and by plan within a carrier.

What plans are available?

This is going to depend on your location. Most areas have the same medigap plans available, but medicare advantage options differ by county. So, you would need to talk to an agent or go to medicare.gov to see all your options.

Answer: There are two types of coverage for your part D needs: a standalone Part D plan, and a medicare advantage plan with Part D coverage (also known as an MAPD).

When you age in to medicare at 65, or become eligible for other reasons, such as disability, you have an Initial Coverage Election Period (ICEP) during which you can make your coverage elections. I recommend at least going through your options at Medicare.gov, but often an agent can help guide you to the coverage that most suits your needs.

If you’re not in your ICEP that raises other questions that are better answered separately.

As for mechanically how you enroll it’s generally done through the provider’s websites. If you are unable to complete the enrollment you can call the provider or reach out to an agent or medicare.gov for assistance.

Answer: There are a couple of ways you can check. First, you can go to your provider’s web site. They should all have a tool where you can enter your medications and see what is covered, at what tier and with what deductible and copay/coinsurance.

If you aren’t satisfied with the results of that search (meds are not covered, or have higher copays than you are willing to pay) you can go to Medicare.gov to look at all your options and see if one has a better mix of coverage and cost, or you can reach out to an agent who can help navigate that process for you. Working with an agent is often the easiest option and won’t cost you anything.

Timing is the hardest part of this as most of the time you cannot make a change to your part D coverage outside of Annual Enrollment (Oct 15th - Dec 7th). There may be other special election periods that apply and an agent can see if there’s anything available for you. It can also make a difference if you have an MAPD (medicare advantage plan with prescription drug coverage) vs a standalone Part D plan.

Answer: If your choice is original medicare with Part D coverage, or a medicare advantage plan with part D coverage (MAPD), I would recommend going with an MAPD.

Many of the copays are going to be lower, you often get ancillary benefits like Dental, Vision, and Hearing that original medicare doesn’t provide. Many MAPDs have no hospital, medical, or drug deductible, and every MAPD plan puts a cap on how much you can be charged for medical services. Original Medicare will charge you 20% of the cost of medical services (after the deductible) with no limit to how high that number can go.

If you’re going the Medigap (medicare supplement) route, then you will should get a standalone Part D plan. In both cases an agent can help you narrow in on the plan that most closely meets your needs.

Answer: You probably know I’m going to recommend working with an agent!

You can go to medicare.gov and look at their plan comparisons on your own, but in a lot of areas there’s an overwhelming amount of choices (including dual and chronic needs plans, my zip code has 64 medicare advantage plans). In addition, many providers offer medicare supplements in addition to Medicare advantage plans, and as you may know Plan G is Plan G no matter who you’re with, so the difference for many clients comes down to how much a provider charges for that service. An agent is usually in tune with the lowest cost provider in your service area.

But beyond price, your agent will work to uncover your needs. Do you take medications that one plan may cover and another doesn’t? They can help ensure your meds are covered by a plan, and if there’s one with better costs they will usually know which one it is. If you have Plan G, do you need dental discounts and a gym membership? Preventive care coverage? Some plans have riders that can help with those needs and your agent will know what is available.

So net - you really should compare your coverage whether you use Medicare.gov, or an agent, but in my humble opinion you’ll save time and frustration by working with an agent.

Answer: Short answer is no, Medicare Part B doesn’t cover the Shingles vaccine but Part D does. Part B covers vaccines like the flu vaccine, Covid-19, pneumonia, and hepatitis B for people at high risk.

Part D standalone plans and Medicare Advantage with Prescription Drug (MAPD) plans will cover it at $0 because of the Inflation Reduction Act.

So - as long as you have Part D coverage, the Shingles vaccine (Shingrix) is covered. You should also know this is typically a two-part vaccine so you should plan on two trips to the pharmacy about 2-6 months apart to get the most protection.

Answer: It depends entirely on your situation. There are advantages and disadvantages both ways, and too many to go through here. Some high level differences:

Medigap provides simpler coverage in that there are no HMO or PPO networks, but you’re going to have premiums to pay on top of your medicare Part B premium, and they typically go up as you age. You also will have to get a separate Part D plan, and purchase Dental, Vision, and Hearing coverage separately, and most likely pay at least the Part B deductible before the plan pays for medical services.

Medicare Advantage plans typically (but not always) have no premium, usually (but not always) include some level of Dental Vision and Hearing coverage, usually (but not always) include your Part D coverage, and may even include a stipend for Over The Counter (OTC) or, with a qualifying chronic condition, healthy food spending, but you will have copays and coinsurances when you use the services, which also typically change year over year.

My recommendation is to talk to your agent and work through your situation to see which one is a better fit for you.

Answer: The process for getting Durable Medical Equipment is typically the same: it all starts with a face-to-face meeting with your doctor. Your PCP must provide documentation about why the wheelchair is medically necessary and it must be for getting around inside the home, not just for going out. They’ll have to confirm that other options (canes or walkers) aren’t enough, and they’ll have to specify what type of chair is needed. Once you have the order from your doctor you will need to work with a DME provider that works with your insurer AND has accepted Medicare assignment.

Once approved, medicare pays 80% of the cost and you pay 20% (this is the same in most medicare advantage plans as well - if you have a medigap plan the 20% is usually covered,)

Note that for a powered wheelchair the requirements for approval are more stringent than for a manual chair.

I hope this helps, and good luck!

Answer: There’s no crystal ball for medication pricing, but after the implementation of the Inflation Reduction Act, the trend has been for more providers to move their tier 3 (Brand Name) medications to a percent co-insurance from a fixed dollar co-pay, and that can drive up the cost of medications.

For example, most plans used to charge $47 for a tier 3 medication. If a med costs $600, and your plan moved to a 25% coinsurance for T3 meds, that’s now $150 per refill instead of $47.

However, if your med costs $120, that’s now a $30 coinsurance rather than $47, so it can work both ways.

In addition, CMS (the government agency that administers Medicare) has been negotiating to reduce the cost of the most common, expensive drugs. Drugs like Eliquis, Farxiga, Jardiance, and Januvia (among others) had prices reduced in 2026. For 2027 the drugs include GLP1s like Ozempic, Rybelsus and Wegovy, COPD treatments Trelegy Ellipta and Breo Ellipta, diabetes drug Tradjenta, and others. However, even with reduced pricing, if your plan moved to a percent coinsurance, your out of pocket cost could still rise.

So the short answer is it’s hard to tell you whether or not the cost your specific mix of medications will go up since there are many moving pieces to the calculation. My advice would be to work with your agent or use the cost estimator at medicare.gov to track your estimated costs. When we get to annual enrollment in October the 2027 drug prices should be loaded into the systems, and medication cost should be one of the pieces of your healthcare puzzle your agent takes into consideration when making plan recommendations.

Answer: Honestly, I haven’t seen much impact in the medicare space. CMS has always had an approved pricing list and most (but not all) of the time the price the client pays is determined by the copay defined in their plan. Having said that I am all for transparency and would love to see healthcare at all levels move to a more standard pricing model.

Answer: Short answer, no, not typically. There are VERY limited exceptions, like if there is no in network cardiologist in a defined radius of your location, but they are very rare. In most cases, your plan will have a number of specialists you can see in network. If you REALLY want to see one out of network, you typically will have to pay out of pocket.

You can also talk to your agent and see if there are any Special Election Periods available to you where you can switch to another plan that has your preferred doctor in network. There are often Special Election Periods available so it never hurts to talk to your agent and see what they can do to help.

Answer: You can wait. You should call Social Security to defer your enrollment if that’s your intention. A lot of people will get Medicare Part A (if they have no premium) at 65 and get Part B when they retire. Just make sure if you have Part A that you don’t also make new contributions to an HSA through your employer insurance after your Part A start date as that can result in tax penalties.

Answer: Doctors or their medical groups may leave or join plans at any time during the year. While it’s not common during the year, it’s not unheard of. More common is a change in the new plan year.

I ran into several cases this past year where the provider’s website listed a doctor in network in October, but as we advanced into December they were out of network for the new year.

Plan reimbursement rates, a provider joining or leaving a medical groups, or choosing not to accept medicare at all are some common reasons for these changes, and often the doctors are finding out about these changes in real time just like you or your agent.

You or your agent can always call your provider and ask them (or their office staff more likely) directly if they’re going to continue with your insurance company in the new year. Then you can change plans to one they do accept, or choose a new doctor before you make any appointments for the new plan year.

Answer: Medicare itself is individually based - your eligibility for part A, B, C, and D, Medigap, etc, are not affected by getting married early or late in life.

However, getting married and combining incomes COULD put your MAGI (modified adjusted gross income) over the limit resulting in higher premiums for both of you when only one would have paid them previously. For example, if a single man has a MAGI of $108,000 he will pay $202.50 for medicare in 2026. But if he gets married and her income takes their combined MAGI to $220,000 they will both pay $284.10 per month, when singly only she would pay the higher amount.

At the other end of the spectrum, Medicaid, Medicare Saving Programs, SNAP, or Federal Extra Help for lower income individuals may be affected, especially eligibility or the level of support from those programs. So if you’re eligible for a Medicare DSNP plan individually, you may lose access to it after getting married if your combined MAGI causes you to lose your eligibility for Medicaid.

But marriage itself will not affect your individual eligibility for Medicare. Since eligibility is based on your age or disability status, there’s no change to when you can get Medicare regardless of when you get married.

Since many considerations are more likely to be triggered by combining incomes and assets, I would recommend you consult a financial planner or tax professional to ensure you have survivor planning in place, and speak to your health insurance agent about your specific situation to see what cost impacts you may face.

Answer: With modern technology, your agent can do everything remote that your local agent can do. (I have clients across the country).

Having said that, your local agent often knows the area better and can relate to your environment better (“that doctor is over on 29th, by the McDonalds!”) and because they tend to work with the local population they can have a deeper understanding of all the plans they offer.

A local agent can come to you, or meet you in person (in their office or a coffee shop, etc),and some people are just more comfortable with someone they can look in the eye in person and not on a video call.

But as I said, I have clients across the country and I take the time to study the plans in their area just like I would if they were here. I think the most important thing is to find an agent that you trust and that takes the time to understand your needs and how the different options can service those needs, be they across town or across the country.

Answer: The Part D IRMAA (Income Related Monthly Adjustment Amount) charges higher income individuals an additional premium for their Part D coverage. Per the Centers for Medicare and Medicaid Services, roughly 8% of the population is expected to pay some level of Part D IRMAA in 2026.

If your Modified Adjusted Gross Income (MAGI) is equal to or less than $109,000 individually ($218,000 married filing jointly), your part D IRMAA is $0. In other words you pay nothing for Part D from Medicare - but since medicare doesn’t actually provide prescription drug plans, you will need to sign up for a part D plan from one of the private insurers (United Health Care, Humana, WellCare, etc) to avoid a late enrollment penalty. The price of the plans available in your area will vary greatly and your agent can help you find the right fit based on your mix of medications. MOST (but not all) Medicare Advantage plans include part D drug coverage.

What if your income is higher than those limits? In that case, Medicare will charge you an additional premium for your access to Part D. Just like your Part B Premium, this additional premium is withdrawn from your Social Security or billed directly by Medicare, NOT by your insurance provider.

Read on for the 2026 Part D IRMAA amounts for higher income individuals, and as always reach out to your agent or Medicare.gov (1-800-Medicare) for additional information.

From CMS:

If your MAGI is over $109,000 but less than $137,000 (single) or more than $218,000 but less than $274,000 (couple) your part D IRMAA for 2026 will be $14.50 per month.

Between $137,000 and $171,000 (single) or $274,000 to $342,000 (couple) the Part D IRMAA is $37.50 per month.

$171,000 but less than $205,000 (single) or $342,000 - $410,000 (couple) the Part D IRMAA is $60.40 per month.

$205,000 - $500,000 (single) or $410,000 - $750,000 (couple) the part D IRMAA will be $83.50 per month

Over $500,000 (single) or $750,000 (couple) the Part D IRMAA will be $91 per month.

Answer: You’re definitely not alone in this situation - in fact it’s very common for people to start with a Medigap plan and face the pressures of increasing premiums as they get older. I don’t think you made a mistake because the coverage of a medigap plan is so good, but you may arrive at a point where a medicare advantage plan is more appropriate based on your income. Remember, though, that with a Medicare Advantage plan you may not have a premium but you WILL have copayments and co-insurances, and network restrictions on the providers you can see. In addition, if you have a lot of medical issues, the Maximum Out Of Pocket (MOOP) may be higher than your medigap premiums for the year so there’s much to consider in making a choice to make the switch. Finally, in most cases you will have to undergo underwriting if you decide to go back to a medigap plan later on, and that gets harder to pass the older we get, so the choice shouldn’t be made in haste.

Another option is to switch to a lower cost medigap plan like a high deductible plan F or plan G, which usually has a much lower premium, but carries a $2950 (in 2026) deductible, which is lower than most Medicare Advantage plan MOOPs, so it’s sort of a blend between the two. You get the same coverage (in terms of the providers) as a regular Medigap plan, with a lower premium and some cost sharing like a Medicare Advantage plan. If you’re relatively healthy this can help you save money overall with a minimized financial risk. Again, you would have to pass underwriting if you don’t have a guaranteed issue window.

Your agent can help you navigate these issues and help you choose the course of action that is right for you.

Answer: It’s important to note that once you’re enrolled in in Medicare, you CANNOT make any new contributions to your HSA or you may incur IRS penalties. If you’re enrolling past age 65, your enrollment could be retroactive up to 6 months so one needs to plan carefully. You also CANNOT use HSA funds to pay a Medigap Premium (like plan G or plan F).

You can use the EXISTING money to pay for Medicare premiums (A, B and D), deductibles, copays, and coinsurances and other qualified medical expenses like dental, vision or hearing. It requires some careful navigation but EXISTING HSA funds can be a big help in managing the cost of healthcare in retirement.

Answer: Medicare by itself does not cover routine vision care (eye exams, eyewear, etc). Nor does it cover dental or hearing services.

Most, but not all, medicare advantage plans offer some level of dental, vision, and hearing coverage. In addition, most agents will have stand alone DVH plans they offer through their contracted carriers.

Your agent can help you with more in-depth questions about coverage and options available to you.

Answer: There are generally two types of supplemental coverage for Medicare: Medigap plans (also called Medicare Supplements) and Medicare Advantage plans. There are pluses and minuses to both types of coverage and depending on your situation one may make more sense than the other.

In this agent’s opinion, you definitely need one or the other because medicare by itself has no limit on your out of pocket costs, and while they handle them differently, each type of supplemental coverage gives you some protection on how much you can be charged in a given year.

Your agent can walk through your specific situation with you and help you decide what is right for you.

Answer: If you have medicare from age 30-39, Medicare covers a baseline mammogram at no cost (as long as the doctor or facility accepts medicare assignment). After age 40, medicare covers a screening mammogram at no cost once every 12 months (again at a provider who has accepted medicare assignment).

Diagnostic mammograms are subject to both the medicare part B Deductible and the 20% coinsurance. This is where supplemental coverage can help with those costs, depending on the type of coverage and the plan in question. Your agent can help you sort through your options.

Answer: Yes, if you’re enrolled in a C-SNP and you fail to validate the chronic condition, the carrier will disenroll you, and you will have a SEP to change to another plan. Your SEP starts when you’re notified and lasts two months past the end of the CSNP plan. So if you were notified your plan will end January 31st, you have until March 31st to make a change. If you changed to another plan in January your coverage would start February 1st, ensuring no gap in coverage. Your broker can help you with this process.

Answer: Medicare Part B does tend to go up every year, as do the Part A and Part B deductibles. As to whether or not, it will be become unsustainable, I think that depends on the individual. For some people, $205 is unsustainable. But this underscores why supplemental coverage is so important. If one has a hard time paying the part B premium, the unlimited 20% copayment under part B will certainly be a hardship. Medicare Advantage or Medigap helps mitigate that.

Depending on your income and other factors, you may be eligible for extra help for prescription coststhrough the federal government, or for Medicaid through your state government. If you think you might qualify, you should go to the Social Security website, or your state’’s Medicaid website and see if you can get assistance.

Answer: If you’ve been collecting Social Security disability income for 24 consecutive months, you may qualify for Medicare. If you have not received any communication about your eligibility, you should contact Social Security and ask them to look into your situation..

Answer: They don’t actually offer gift cards, but they may offer benefits that include Over The Counter (OTC) or Special Supplemental Benefits for the Chronically Ill (SSBCI). In addition they may offer other benefits like dental, vision, hearing, and rewards for physical activity or certain healthy activities like getting your wellness exam, getting your flu shot, etc.

Not all plans offer all of these benefits. It depends on the provider and the market and the plan you enroll in. Your agent will work with you to determine your unique situation (doctors, medications, chronic conditions, etc) and any other benefits that are important to you (like higher dental coverage, or lower Maximum Out Of Pocket cost (MOOP)).

I don’t consider it suspicious as a good agent will generally use those OTC, SSBCI and rewards benefits as pieces of the coverage puzzle, not typically the sole reason for making a change.

One exception could be people who receive Medicare AND Medicaid, as they have access to a different type of medicare advantage plan, but that’s a longer answer than we have room for here.

Answer: It depends.

As far as your Medicare Parts A & B, that coverage is nationwide. You don’t need to do anything with it.

If you have a Medigap plan, that coverage goes with you. Some states have different rules about community rating or medigap enrollment windows, so in SOME cases it would be wise to look at your options, but in general, medigap is portable there’s nothing you need to do.

Medicare Advantage plans are local - so you would need to enroll in a new plan in the new area. This applies even when moving to a different county in the same state. Even if you just move to the county next to yours, you will have a Special Election Period (SEP) because you’ve changed your service area.

Part D coverage is also local and you’ll need to shop for plans in the new service area.

Answer: If you are a US citizen or lawful permanent resident (with 5+ years of residency) you CAN enroll in medicare, but your cost will likely be different if you’ve never paid into the system.

Part A is premium free if you’ve worked for 40 quarters (10 years) and paid into the system. If you don’t meet that requirement, you can BUY part A coverage.

Part B would be handled the same as everyone else - you’ll pay the premium appropriate for your income.

Your supplemental coverage (Medicare Advantage, Medigap and/or Part D) are based on your medicare eligibility and not based on your social security contributions.

NOTE - Foreign work credits from countries with TOTALIZATION agreements with the US (ie Canada, the UK, Germany) MAY count toward the Social Security eligibility and COULD reduce or eliminate the Part A premium. Also, if you’re married to someone with US Work Credits that can make a difference, so there are a lot of variables to this situation. Social Security can help you determine what comes next.

Answer: It’s quite possible. With the Inflation Reduction Act and the removal of the coverage gap, many providers have changed how they’re handling prescriptions, including:

- copays where there were none before

- higher copays than were previously in place

- deductibles where there were none

- deductibles on all tiers of medications (where before it was only for T3, 4 and 5, for example)

- Higher deductibles than were previously in place

- percent co-insurance rather than fixed dollar copays

- formulary changes that treat some generic drugs as T3 preferred brand

There may be other changes as well, but these are the most common ones I’ve seen over the last two years. An agent would have to work with you on your specific medications and coverage to see what is driving the increase in cost.

Answer: Absolutely. I’ve worked with dozens of POAs over the years who make all the decisions because the beneficiary is either physically unable to, or doesn’t understand the choices they’re making. Generally, you should consider a medical POA regardless of your situation to ensure your best interests are looked after should something catastrophic happen.

Answer: No, as long as you have CREDITABLE COVERAGE (insurance that provides coverage at least as good as Medicare’s) you do not have to apply for Medicare. MOST employer plans are going to be creditable, but you’ll want to check with your benefits administrator as you can pay a hefty late enrollment penalty if medicare later determines your coverage wasn’t creditable.

Then, when you’re ready to retire and need to sign up, you’ll want to reach out to social security as soon as you know the retirement date to ensure you know what to do next. Generally you’ll need your employer’s plan information to prove you had creditable coverage. Once you have your A and B start dates, and you’re within 90 days of that date, you can sign up for your additional coverage.

At a minimum you’ll need Part D coverage, but I really recommend Medicap or Medicare Advantage to protect yourself financially. A good agent can help you determine which path is right for you.

Answer: I enjoy being able to help people, and feeling like what I do makes a positive difference in people’s lives. After 20+ years in the tech industry, this has been a refreshing change of pace, and while I miss some things the corporate world provided (primarily, and ironically, health insurance) I do NOT miss corporate life at all. I love what I do and honestly wish I’d made the decision to start doing it sooner.

Answer: As of now (2025) if it’s medically necessary and ordered by a medicare participating doctor, genetic testing MAY be covered. Most preventive or elective testing will NOT be covered. If it’s diagnostic and part of a treatment plan (for cancer treatment, for example) it might be covered. Your best bet is to work with your doctor regarding the specific test, but know in advance if it’s elective it likely won’t be covered.

Answer: People who have been on social security disability income (SSDI) for 24 months generally already have Medicare, but will get a second Initial Enrollment Period (IEP) when they turn 65. If you don’t have medicare but are on SSDI, when you turn 65 you generally WILL be signed up for medicare automatically, but I always recommend double checking with social security anyway, especially if you have not received anything from them about the start of your coverage.

If you’re only receiving Supplemental Security Income (SSI) you need to call social security to sign up.

Answer: There is generally no better time to sign up for a medicare supplement (medigap) plan than when one’s medicare coverage begins. This is because for 6 months from the date medicare coverage begins, one can enroll in a medigap plan with NO MEDICAL UNDERWRITING. This open enrollment period (OEP) is considered GUARANTEED ISSUE because the providers MUST accept you regardless of any pre-existing conditions.

You may get other guaranteed issue (GI) opportunities, like if your Medicare advantage provider terminates your plan, or you move to a new service area and need to change your coverage. Other than OEP or the special GI situations, you will need to go through underwriting to enroll in a medigap plan. During underwriting, a provider can deny coverage for specific pre-existing conditions, for taking specific medications, or for having recommended but unscheduled surgical procedures in place.

Answer: The short answer is that this depends on the individual’s medications. Someone with multiple expensive Tier 3, 4 or 5 medications may potentially save a fair bit of money. For someone with a mix of tier 1 and tier 2 medications likely won’t see a difference since the copays are generally low enough the costs typically wouldn’t reach the old coverage gap anyway.

However, more providers are adding deductibles to their coverage now, so people with even lower cost tier 3, 4, and 5 medications may see their out of pocket increase as they’ll pay the full cost of those medications until the deductible is met. In addition, many plans are moving from a flat dollar copay to a percent coinsurance (usually 25% of the cost of a tier 3 medication), so a medication that used to cost $47 per refill now could be $150 per refill after the deductible is satisfied.

The best way to understand the individual impact is to either work with an agent or go to medicare.gov and enter the medications to see how the plans handle their specific mix.

Answer: A licensed Medicare agent helps you understand and will present your options, avoid potential mistakes, and choose coverage that actually fits your doctors, medications, and budget. The help costs you nothing, and the guidance can save you time, money, and frustration both now and down the road. A good agent will find your pain points and what your primary concerns are, and work to match your coverage to your needs. As medicare changes, they must keep up with the differences year-over-year, which means you don’t have to.