Robert Vaughan, R.Ph., MBA, Medicare Insurance Broker

Answer: Using my knowledge and experience to educate people about Medicare. It is my responsibility, as a Medicare agent, to educate my clients about Medicare and lay out all of their options so they can make an informed decision about their Medicare coverage.

Answer: It is true that many Medicare Advantage plans have zero dollar premiums, but there are costs associated with utilizing the plan's benefits. You will likely pay deductibles, coinsurance, or copayments when seeking medical treatment. Additionally, continuing to pay your Medicare Part B premium is necessary to remain enrolled in a Medicare Advantage plan.

Answer: No, not mid-year. You can use the Medicare Advantage Open Enrollment Period (MA OEP), which runs from January 1 to March 31 each year, to return to Original Medicare and apply for a Medicare Supplement (Medigap) plan. The issue here is serious illness, which would likely disqualify you from Medicare Supplement plans. You have 6 months from your Medicare Part B effective date to enroll in a Medicare Supplement plan without going through underwriting. Insurance companies can deny your application for a Medicare Supplement if submitted outside of this 6 month window.

Answer: If you have a body-mass index (BMI) greater than or equal to 30, Medicare covers obesity screenings and behavioral counseling to help you lose weight by focusing on diet and exercise.

Medicare covers some bariatric surgical procedures when you meet certain conditions related to morbid obesity.

Conditions that must be met to qualify:

The beneficiary has a body-mass index (BMI) greater than or equal to 35.

The beneficiary has at least one co-morbidity related to obesity such as cardiovascular disease, chronic obstructive pulmonary disease or type 2 diabetes mellitus.

The beneficiary has been previously unsuccessful with medical treatment for obesity.

Answer: If you choose to maintain your Medicare coverage while living abroad, you are still responsible for paying the monthly premiums, especially for Part B. If you fail to pay for Part B while abroad, when you return to the U.S. you may go months without health coverage. This is because you may have to wait until the General Enrollment Period (GEP), which runs January 1 through March 31 each year, with coverage starting the first of the month after the month you enroll.

While Medicare generally does not cover services outside the U.S., you can keep your coverage for when you return.

Answer: Original Medicare provides access to healthcare services throughout the United States. This encompasses all 50 states, the District of Columbia, as well as the territories of Puerto Rico, the U.S. Virgin Islands, Guam, the Northern Mariana Islands, and American Samoa.

Answer: Medicare Part B covers occupational therapy as long as it is considered to be medically necessary and your provider recommends it. There are no limits to the number of occupational therapy sessions Medicare will cover, but you will pay 20% of the Medicare-approved rate after you have met your Part B deducible.

If you are an inpatient in a hospital or skilled nursing facility, occupational therapy is covered under Medicare Part A.

Answer: Intensive Outpatient Program (IOP) services are covered under Medicare Part B and include intensive psychiatric care, counseling, and therapy. These services are provided in hospitals, Community Mental Health Centers, Federally Qualified Health Centers, Rural Health Clinics, and Opioid Treatment Programs (when services are for the treatment of Opioid Use Disorder).

The beneficiary will pay 20% of the Medicare-approved amount after the Part B deducible has been met.

Answer: As long as you continue to pay your Medicare premiums nothing will happen to your Medicare coverage, but Medicare does not pay for long-term care. You will be responsible for 100% of the cost of your long-term care.

Answer: You are paying more for your Medicare Part B and Part D premiums due to the Income-Related Monthly Adjustment Amount (IRMAA). IRMAA is a surcharge added to Part B and Part D premiums for those with higher incomes, based on their Modified Adjusted Gross Income (MAGI) from two years prior. You can find your MAGI on line 11 of your IRS Form 1040. The Social Security Administration (SSA) determines IRMAA amounts based on income brackets, and these brackets are adjusted annually for inflation.

If you disagree with the Income-Related Monthly Adjustment Amount (IRMAA) that the Social Security Administration (SSA) has determined you need to pay for your Medicare Part B and/or Part D premiums, you have the right to appeal.

How to Request a Reconsideration:

Complete and submit Form SSA-44 (Medicare Income-Related Monthly Adjustment Amount - Life-Changing Event).

Provide supporting documentation: This may include tax returns, marriage/divorce certificates, employer statements, and other evidence relevant to your specific situation.

You can contact the SSA at 1-800-772-1213 for assistance with the reconsideration process and documentation requirements.

Answer: Your first step should always be verifying their insurance license information on the state’s Department of Insurance (DOI) website. Beware of door-to-door sales; Medicare agents cannot solicit business at your home without an appointment and Medicare will never send an agent to your home to enroll you into a plan. A legitimate Medicare agent will take the time needed to understand your specific needs and recommend products to meet those needs. Look for an agent that represents multiple private insurance companies. They should lay out all your coverage options (Medicare Supplement plans, Medicare Pharmacy (Part D) plans, and Medicare Advantage plans) and provide unbiased guidance. You can also search the internet (Google) to see if they have any reviews or ask for client references.

Answer: Part D of Medicare is your prescription drug coverage. These plans are offered by private insurance companies, and cover both brand-name and generic medications. The main benefit of Part D plans is helping to reduce the financial burden of medication costs for Medicare beneficiaries. The Inflation Reduction Act (IRA) lowered the out-of-pocket cap for covered medications to $2,000 in 2025.

Answer: Yes, Medicare Supplement Plan G will cover all Medicare-covered costs associated with a knee replacement, except for the Part B deductible. If the procedure is covered by Medicare and deemed to be medically necessary, your Medigap Plan G will cover all costs with the exception of your Medicare Part B deductible.

Answer: Medicare agents or brokers cannot contact you to solicit Medicare Advantage or Medicare Pharmacy (Part D) plans without your explicit prior consent. If the caller identifies themself as being from Medicare, or is requesting personal information like your Medicare number, Social Security number or banking information it's a scam. The first question you should ask them is what is your state insurance license number?

Answer: Medigap Plan F covers all costs associated with an emergency room visit. Plan F will cover all medical costs as long as they are covered by Medicare and considered to be medically necessary.

Answer: Original Medicare (Parts A and B) does not cover hearing aids. Some Medicare Advantage plans offer additional benefits, which can include hearing exams and hearing aids.

Answer: The Scope of Appointment (SOA) form is required to be signed 48 hours prior to any scheduled appointment where Medicare Prescription Drug (Part D) plans or Medicare Advantage (Part C) plans benefits are being discussed. The SOA lays out what will be discussed during your appointment with the agent/broker. Only plan types selected on the SOA can be discussed during your meeting. It must be signed by both the Medicare beneficiary and the Medicare agent/broker. The form is a Medicare requirement and all agents, included call center agents, are required to comply with the regulation.

There are three exceptions to the 48 hour rule:

1) Walk in without prior appointment

2) Inbound call initiated by the beneficiary

3) Within 4 days of the end of a valid election period