Robert Simm, Medicare Insurance Broker

Why are people unhappy with Medicare Advantage plans?

Answer: I think the media plays it up a little bit more than what the true reality is. Do the insurance companies require pre-authorization from the providers on the services they provide that question is a hard yes. Traditionally the one plan that would get the most prior authorizations would be a plan on HMO coverage versus PPO. If a Medicare beneficiary is going to be utilizing a lot of medical services for the calendar year then it might be worth it to take a look at a PPO plan to see if they can remove some of the authorizations.

I picked a Medicare Advantage plan based on the low premium, but now I'm facing high copays. Did I make a mistake?

Answer: Maybe. There are zero premium plans in your market that could have lower co-payments and it would also depend on the use of your coverage and how many providers you're currently seeing at this time. I always recommend a second opinion on Medicare Advantage plans it is worth it to see if you can save some money on your medical expenses.

Does Medicare cover cancer screenings, and how often can I get them?

Answer: Great question! Coverage for Colorectal Cancer Screenings is once every 12 months.

and covered at 100% if performed by a Medicare-approved provider.

Flexible Sigmoidoscopy is every 48 months for average-risk individuals; every 24 months for high-risk individuals and is covered at 100% if performed by a Medicare-approved provider.

Colonoscopy every 10 years for average-risk individuals; every 2 years for high-risk individuals.

The cost is overed at 100% if it's a screening colonoscopy. If a polyp is found and removed, you may have to pay coinsurance for the diagnostic portion.

So I heard something about Medicare drug costs being capped at $2,000 in 2025. Is that really happening or just talk?

Answer: That law has gone into effect and medications are capped at $2000.00 for the year. If the medication is on a tier 3 then most insurance companies would apply that particular medication towards the deductibles so there will be a very high cost on medication in January then it starts to lower the co-payment throughout the rest of the calendar year the insurance companies do have a plan that helps Medicare beneficiaries with the high cost of medication so they can stagger that co-payment throughout the calendar year if need be.

I picked the plan with the lowest premium, but now every doctor visit feels like a surprise bill. Should I have gone with a higher premium instead?

Answer: That would be dependent on the medical service you received once you saw your provider and how that claim was coded to the insurance company and then if that claim was paid or not through the carrier. This is a perfect example of utilizing a health insurance broker experience when it comes to your medical expenses. I personally have been in this situation with my clients before and once we've done the investigation traditionally we find the doctor's office was at fault on submitting the CPT codes correctly to the insurance company. To answer your question, a higher premium doesn't always translate to lowering your cost on your medical expenses when you use the insurance and receiving medical treatment.

I'm living solely on Social Security of $1,400 monthly and can't afford my Medicare premiums and copays. What assistance programs might help someone in my situation?

Answer: Dependent on your state then you should be receiving help with your part D prescription drug coverage and possibly reach a subsidy level through the state to cover your part B premium.

I keep hearing about Medicare Part D changes for 2025. Will these actually lower what I pay for my prescriptions?

Answer: For the majority of Medicare beneficiaries that have Tier 1 or tier 2 medications then they won't feel the impact of the new law under the Inflation Reduction Act. If your medications are coming up a little expensive when you pick them up at the pharmacy you can always reach out to your health insurance broker or insurance company to ask them if there's any reduction that you could possibly get for the cost of the medications or you can ask your provider to see if there is a financial incentive for the manufacturer the medication to reduce that cost there for you.

I'm turning 65 next month and the amount of Medicare mail I'm getting is overwhelming. How do I sort through all this?

Answer: I'm sorry that you're having to go through that but unfortunately since you are turning 65 a lot of the insurance companies are responsible for this type of marketing along with maybe some smaller brokerage firms. I would recommend contacting your local health insurance broker which you can find easily on Medicare agents hub and that would probably be the best solution when you're coming into Medicare for the very first time.

Will Medicare Advantage plans start offering more digital health tools like apps by 2030?

Answer: Traditionally the majority of the insurance companies have some form of an app which functions as a ID card along with claims and benefits so you can see the history of medical services and what's been paid by the insurance companies I would think within reason the insurance companies will start to expand the apps and to other tools they can offer for weight loss, diabetes management, respiratory issues.

I'm confused by all the star ratings for Medicare plans. Do they actually mean anything for the care I'll receive?

Answer: The answer to that question is a no on the star ratings. The star ratings would cover for customer service, preventive care, managing chronic conditions and, plan Administration meaning is the carrier paying for your medical expenses or not. I would recommend a three to five star plan rating because it could have some form of impact on your health insurance whether you knew it or not.

How could a universal healthcare debate shift Medicare's structure in the next decade?

Answer: Unfortunately I don't think universal healthcare in the United States will ever happen United Healthcare is the fourth largest company in the United States. It would be better if we had a Medicare for All and that would include ages 19 through 65 Plus.

Does IRMAA go away automatically if my income drops, or do I need to report it to Social Security?

Answer: If your income were to decrease then I would highly recommend reaching out to the Social Security Administration and Reporting the current income so this way you could be removed from the so this way you could be removed from the IRMAA penalty.

Does Medicare cover emergency care if I'm traveling in a U.S. territory like Puerto Rico?

Answer: Puerto Rico would be a covered country since it is underneath the United States but if you were to travel to Mexico and then I would highly recommend a worldwide emergency room coverage plan that the insurance companies are offering. Unfortunately there's only a few carriers that offer this type of coverage.

What happens if I delay Medicare Part A enrollment because I'm still on my spouse's employer plan?

Answer: It seems like Medicare has a penalties for their coverage whether it's A, B, D. I would recommend enrolling into part A since it is free to you and your entitled to it and your wife's employer insurance will be the primary and Part A would be the secondary if your were hospitalized. If you decide to stay on your wife's employer plan then I would recommend to delay the Part B premium but Medicare does have specifications for group coverage that must be followed to avoid the Part B penalty.

I applied for a Medigap plan and got denied because of my health history-how is that even legal when I've paid into Medicare for years?

Answer: When we pay into Medicare what we're really paying into is part A coverage which is inpatient hospitalization. That includes nursing homes rehab centers hospice along with hospitalization.

We have also paid into the Medicare system to reduce cost for Part B premiums along with out-of-pocket medical expenses like deductibles. When we first age into Medicare under the 12-month rule we have an option to move from Medicare Advantage to Medicare supplemental plan with original Medicare and a separate Part D prescription drug plan or you could just simply go with original Medicare Parts A and B along with a prescription drug plan. Within that 12 months everything is guaranteed acceptance. When you aged into Medicare the person should have explained the process on Medigap versus MAPD versus original Medicare. The insurance companies have a legal right to underwrite for risk and if they view a person as a high risk then they do have the right to deny the coverage. After the first year then Medigap underwriting will always continue until there's some government change for those plans.

I chose Original Medicare to keep my doctors, but now I'm drowning in bills. Should I have gone with Advantage instead?

Answer: If you went with a Medicare Advantage plan then that would be dependence on your area and what the insurance companies are offering on a Medicare Advantage plan. What I mean by this sentence is if you're on an original Medicare then after your deductible you will pay 20% of any outpatient medical expenses. That 20% could be more than a copayment tied to a Medicare Advantage plan. If you are using a tremendous amount of your health insurance then it would be advisable to compare original Medicare versus Medicare Advantage then if you can qualify for a supplemental plan then it might be worth it to take a look at that product as well to help reduce the cost of your medical expenses.

I called to ask about a knee replacement and suddenly they said I need prior authorization. I thought my plan was supposed to be good-what's going on?

Answer: Prior authorization should be between your providers and your insurance company. Your providers are responsible to sending out the correct CPT codes so this particular procedure can be approved and then completed by your doctor's office. If your doctor's office is calling you a letting you know that you need prior authorization and then that is incorrect information. The doctor's office is always responsible for these prior-auth medical services.

Is paying for a high-end Medicare Supplement plan really worth it, or is it overkill?

Answer: That would be dependent on the coverage of what you might be receiving on a high-end Medicare supplemental plan, but in my professional opinion it would be overkill the reason why. Once these supplemental plans came to Market, the states quickly decided that they should have a standardized coverage so if you purchase a plan G from UHC it's the same plan G as a Physician's Mutual. The coverage is identical, the only difference is a premium.

What's the likelihood of Medicare covering gene therapy as it becomes more common?

Answer: This is a interesting question because I do believe this is a interesting question because I do believe in DNA results to treat future possible diseases. In which MediCare at this time is not covering that particular test so I don't think in the near future we will see gene therapy as a cover procedure by Medicare.

I live in California but might move to another state next year. How will my Medicare coverage change if I relocate?

Answer: This is a great question and it's very common for seniors to move closer to family members. There would be no change on your Medicare coverage because it follows you, and it doesn't matter the states in which you will move to. If you're on a Medicare supplemental plan the you do not have to do anything if you like. I would recommend shopping the supplement of plan because the premiums can be based on the community which you will move from. It is possible that you might be on that type of plan I would call your carrier to find out or your health insurance broker. If you are on a Medicare Advantage plan and then yes you will need to change into a another make Advantage plan based in your new zip code and county. If you have original Medicare and a prescription drug plan and then you would need to change your prescription drug plan.

I need a new wheelchair, and I'm not sure if Medicare will cover it. What's the process for getting durable medical equipment?

I changed my plan during Open Enrollment and now I can't see my regular specialist. Isn't this what the whole review period is supposed to prevent?

Answer: You're going to get a lot of responses that are going to be completely different from one agent to the next we will all have different answers to the same question.

I'm assuming you gave the person that you were speaking with about your healthcare information on your specialist's. And this person said "they are in network". And off you go completing the application thinking that everything is perfect and then when you go to the doctor's office you show on the card, and unfortunately they do not accept it.

What do you do? You can get that person on the phone to see if they can help you, you can try the insurance company to see if they can help you, or you can pick any of the five+ brokers who have answered your question.

You have an answer faster with the 5 plus brokers then with your insurance company, and then on top of trying to get a hold of that guy that signed you up back in AEP.

Don't you think Medicare should ban all those celebrity Medicare Advantage commercials?

Answer: 100% yes please for the love of God destroy those commercials it is the most hurtful thing they can do to somebody like myself who's been on the brunt end of those commercials for years we're starting to make changes to make the experience of getting a Medicare health insurance plan easier for everyone.

I tried calling Medicare and got transferred five times. Is there any way to get straight answers from them?

Answer: That would be dependent on who you talk to. If you're on original Medicare and you needed to call your health insurance company cuz he had a question and you couldn't find anybody to answer that question, would you find a different Insurance Company?

What does Medicare Part B cover? Is it enough?

Answer: Medicare Part B will cover all outpatient services. Which includes primary care doctor, specialist outpatient Imaging or lab, outpatient physical therapy, occupational mental therapy, outpatient surgery, out-patient hospitalization, surgical center, durable medical equipment, and chemo and radiation centers as well too. Once you have paid your deductible of $257 then you are responsible for 20% of all medical expenses. I would highly recommend either a Medicare supplemental plan or make your Medicare Advantage plan to at least cap your outpatient medical expenses.

I just moved to a new state. Do I need to do anything with my Medicare coverage?

Answer: That would be dependent on the current coverage you have right now. If you're on original Medicare with a prescription drug plan, then you would need to update your address with Medicare along with Social Security Administration. Typically, you could do that online if you have an account with them. If you happen to have original Medicare along with a medigap plan with prescription drug coverage, then you will need to update your address with all three entities. If you have a Medicare Advantage plan, then you would need to change your plan along with Medicare Social Security Administration. If you have a health insurance broker that you work with on a yearly basis, then you could reach out to that person for assistance. They may have a non-resident license in a state in which you are moving too, and they will be able to assist you with your on-going Medicare issues.