Roberto Alonso, Medicare Insurance Agent

Answer: Though Medicare is a Federal program and as such it is pretty much standard nationally, there are some differences in pricing and benefit designs in each particular state.

Medigap plans must follow nationally published standard benefits, but the pricing differs. You might want to check this out if moving to a different state, although your benefits will be the same.

Medicare Advantage, will probably have differences in available networks of providers, pricing and benefit designs, and if you move out of state, you'll probably will need to change to the new state's plans.

Answer: The old time honored monicker applies: "caveat emptor" let the buyer be aware.

You must be prepared when you first aproach the Medicare subject with an agent. What can your budget allow?, what is important to you when it comes to freedom of choice?. Do you travel? do you take more than five prescribed medications for a chronic condition?.

You must first answer all these questions honestly to yourself, then seek guidence in plan selection from an agent.

Most, in my experience as an agent, are honest and do care about their clients.

Answer: Yes they can, by increasing the Modified Adjusted Gross Income( MAGI) on which Medicare is based to compute( two years in arrears) surcharges( Income Related Monthly Adjustment Amount -IRMAA) based on income for Medicare Part B and Part D premiums.

Some time planning is suggested to mitigate the impact, which could be substantial.

Answer: Original Medicare is made up of two parts. They are Part A(Hospital), and Part B (doctors).

Other parts of Medicare include Part C( Medicare Advantage) and Part D( Prescription Drug Plans).

Answer: What most Medicare beneficiary enrolles will pay in 2026 is $202.90, up from $185.00 in 2025.

I say most, because beneficiaries making over $109,000 as single tax filers or $ $218,000 for joint filers for tax year 2024, will pay more based on their IRMAA( Income-Related Monthly Adjustment Amount) adjustment.

The based price is adjusted for annual cost of living inflation rates.

Answer: I will assume that mom is aproaching 65 and has a few years, say five years, before she does turn 65. If this is so, first question to ask is what does the budget allow for to cover the Original Medicare( Parts A&B) gaps in coverage, and will Mom be doing some traveling to visit relatives and such? In other words, how important is freedom of provider choice, and can she afford to have such freedom?. The honest answer to these, will usually point to the right decison in plan selection.

The Long Term Care Insurance (LTCI) issue, is much more time sensitive because one of its major factors are age and health history. Your finances pay for the plan's premium , but your health actually buys the coverage. Keep in mind that the benefits of an LTCI will be probably used in the latter part of the decade of your 70's or beyond, so think inflation rider. The typical policy runs for 2 to 3 years of benefit. Try making the LTCI policy a Tax Qualified State Partnership policy.

Answer: I would advice against it. There are strict rules and regulations that must be observed in the Medicare field. Rather, I would call Medicare at 1-800-633-4227 and request advice as to how to proceed.

My experience with this Federal Agency has been very good trough the years. They are corteous and well trained.

Answer: Comming from the life insurance market segment into Medicare at this stage in my career path, I fail to see the connection between these two markets cited in the question.

Though both fields impact greatly the financial well being of eligibles and members, each market answers to different needs and have their special life focus. One is a privileged financial tool to preserve and settle an estate at any age, the other, Medicare, deals with access to healthcare in the later stages of life. Both critically important to the healthy well being of folks, both financially and healthwise.

Answer: The SOA(Scope Of Appointment) must be completed by the licensed agent and signed by both the member and the licensed agent.

The administrative staff can assist in the distribution, collection, or help organize the form pre-appointment, but not sign or complete the agent portion or fulfill any of the agent's compliance duties and functions.

There are no special exemptions for the US Virgin Islands( USVI), any of the territories, or the Continental USA for that matter.

Answer: In my practice I make extensive use of www.medicare.gov , for me, probably one of the best resources made available by the government to American taxpayers, specially Medicare beneficiaries.

Answer: In this instance, the question itself is a bit confussed. Every part of Medicare has a time frame for enrollment and plan changes. Each time frame dictates when and what plans you can enroll and/or disenroll, and will there be any penalties involved in the election.

Original Medicare( Parts A & B), do not have medical questions, neither does Part C( Medicare Advantage, or Part D-Prescription drug plans) for that matter.

In contrast, Medicare Supplement Plans , which you can buy anytime of the year, are basically only guaranteed issueduring your once-in-a-lifetime- Initial Election Period when you turned 65 or became Medicare eligible due to a disability, if your under 65.

Answer: Your Medicare Part A covers you as In Patient in a Hospital setting. You'll need to satisfy the Benefit Period deductible first. This amount is adjusted annually by CMS.

Answer: Simple answer, yes, sort of.

Part A( Hospitalization, and In Patient) premium you paid for( out of your FICA taxes) during your 10 years of continious working in the USA. So Part A is usually premium free to most taxpaying Medicare eligibles.

Your Part B (Physicians and Out Patient) has a standard monthly premium published every year and adjusted for inflation, but is subject to an IRMAA monthly adjustment based on your income from the previous last two years before current. Same for Part D( Prescription drugs).

Answer: Short answer is yes, but within certain guidelines.

There are eligible Medicare premiums you can pay with HSA funds. Things like Medicare Part B premiums, Medicare Part D premiums, Medicare Advantage( Part C) premiums, IRMAA surcharges for Medicare Part B or/and Part D and your share of employer-sponsoredretiree medical premiums. These are all considered qualified medical expenses for HSA purposes.

You may not use HSA funds to pay for Medigap premiums, this is specifically prohibited by the IRS. Also keep in mind that you must stop your HSA contributions once you are enrolled in any part of Medicare. Part A,B,C, or D

Answer: Yes, because ultimately we all pay for it.

Next time you review your EOB letter or your annual ENOC letter from your plan, be mindful of what they say. Carefully review your electronic messages from Medicare.gov when you receive services. Do not just assume, be smart and review these documents carefully.

Report any waste, abuse or fraud.

Answer: Original Medicare parts A & B do not have a Maximum Out Of Pocket Limit, one of the gaps that many tend to ignore or not realize. There is no limit to your financial responsibility, deductibles, coinsurance, and copays, during the calendar year.

One of the advantages of Medicare Advantage plans is that they do place a cap on your out of pocket expenses during the plan's benefit period which coincides with the calendar year.

This same limiting advantage applies to Medigap plans, though the benefit model is different, and to many even more advantegeous.

MOOP is also known in the field as the STOP LOSS of the plan, In Network and Out of Network.

Answer: Diagnostic non-laboratory tests like MRIs, are a covered and are usually a Part B expense, but the final cost and coverage will depend on where you have it performed.

if you have the diagnostic test performed as in patient in a hospital setting, intead of an accreditted free standing facility, then there will be a Part A Deductible involved, and it will end up being more out of pocket for you.

Check always that the test is medically necessary and that the facility is a Medicare acredited one, before having the test performed.

Your Medigap Plan N will pay the 20% coinsurance of the Part B coverage after you satisfy the Part B deductible( $257 in 2025). There should be no further out of pockets, if you dealt with providers and facilities that do accept Medicare assignment in the Medicare accredited free standing facility. No big bills involved if you first did your homework.

Answer: Tha is correct, and it is unfortunately very common. Most Opthalmologists I know, will assist their patients in informing themselves as to which lenses are covered and those that are not.

Always check coverages before having any procedure performed.

Answer: It is not.

If your employer's group health plan has 20 or more full time employees, you can hold off enrolling in Part B until you retire, and skip paying its monthly premium. Same goes for Part D (drugs), if the employer's prescription drug coverage is "creditable".

Part A is "premium free" as long as you worked and paid taxes for 10 years in our country. Part A is a no brainer. There you have it. Which part was difficult?

Answer: OUTSIDE OF THE ONCE IN A LIFETIME INITIAL ELECTION PERIOD WHEN YOU ARE TURNING 65 AND HAVE MEDIGAP GUARANTEED ISSUE RIGHTS TO ENROLL IN A MEDICARE SUPPLEMENT PLAN, THESE PLANS ARE MEDICALLY UNDERWITTEN SO THE INSURANCE COMPANY CAN DECLINE YOU OR MODIFY AND LIMIT YOUR COVERAGE.

THERE ARE EXCEPTIONS TO THIS GENERAL RULE, LIKE IF YOUR INSURANCE COMPANY LEAVES THE MARKET AND TERMINATES YOUR PLAN. SO WHILE YOU CQN CHANGE PLANS ANY TIME OF THE YEAR, BE MINDFUL THAT YOU WILL USUSALYY HAVE MEDICAL QUESTIONS TO ANSWER.

Answer: By providing a "discounted dollar " approach to financial issues and estate needs. More on this in subsequent text.

Answer: Simply stated the answer should be, no. But very little is simple in the Medicare market segment.

You have to do your due dilligence before enrolling in a plan, specially Medicare Advantage plans.

There are some MA and MA-PD plans that do cover while your traveling. Usually they are based on national or regional Networks, and as such you can be out of your service area and and temporarily be covered. Other plans do not extend this benefit and you'll be out of pocket for the entire cost of the medication or service, other than life or death emergency situations.

Answer: I can not comment on what you have heard but I will take it for granted that you did hear these stories, and they make me feel bad for those that went trough any unsatisfactory experiences.

Here is what you need to know; starting in January of 2026, the Total Out Of Pocket maximum for prescription medications, including diabetic medications, is capped at $2,100 after which you are covered at 100% by your Part D plan, regardless as to what benefit model you buy it trough.

All covered insulins under Part D are capped at $35 per month, with no deductible. This applies to either a Stand Alone PDP plans or a MA-PD.

The cost of other diabetics drugs, and most importantly the more expensive brand name offerings that are covered under the plan's formulary, will depend on the tiering the plan calls for. Based on what tier they fall under, you'll be responsible for the plan's deductible, copayments and coinsurance. So carefull review of the Summary of Coverages and the Formulary of any given plan is critical prior to decision making regarding plan changes.

Answer: No. Open Enrollment allows you to, after reviewing your ANOC letter back in September( Annual Notice Of Changes), perform your due dilligence and check your providers and medications in the proposed plan you are considering changing to for an effective date of 01/01/2026 , in this case.

Keep in mind that you can select a new Medicare Advantage plan that does include your primary before December 7th, and this process will automatically disenroll you from the one you selected previously.

Answer: Your Medicare coverage goes with you into a CCRC, you do not lose your coverage. But you must excersice care and caution before entering into any CCRC agreements.

There are questions to be answered before you commit. Do they bill Medicare for medical services, what custodial and /or routine care is included in the contract, are there monthly fees and what do they exclude.

Answer: Medicare Savings Programs ( MSPs) are state-run assistance programs that help low income and/or resources Medicare beneficiaries pay for some or all their Medicare costs.

These programs are funded by Medicaid but designed specifically to help Medicare beneficiaries.

Upon qualification the program can help you pay for:

Medicare Part A premium, if you owe one.

Medicare Part B premium.

In some cases even Parts A and B deductible, copays and coinsurance.

There are four MSPs programs: QMB Qualified Medicare Beneficiary, SLMP Specofoed Low=income Medicare Beneficiary, QI Qualifiying Individual, QDWI, AQualified Disabled and working Individual.

Income and asset limits vary by state. Most states also have resource limits.

When you quslify for any SSP, except QDWI, you are automaticaaly enrolled in "Extra Help" for Medicare Part D which lowers your Presciption drug premiums, deductibles and copays.

Answer: The old "donut hole" phase was eliminated effective January first, 2025, and was replaced by a single out-of-pocket cap (OOP) for covered drugs: you pay up to that cap, after paying the plan's deductible for certain tiers, then the plan covers 100% of your covered Part D drugs for the rest of the year.

For 2026, the cap has been increased to $2,100 due to annual indexing, and the standard deductible is increasing.

Answer: First question to my new Medicare client. Who do you wish to be paying your claim first, Medicare (the government's insurance), or an Insurance company?. Why, does it matter?

Well yes it does. With the government you can go to any doctor or provider that accepts Medicare assignment, and in most cases, even to doctors that do not accept Medicare assignment but have not completly opted out of the system.

With an insurance company replacing Medicare, like in a Medicare Advantage scenario, Medicare pays the company and charges the company with taking care of your health care needs, and then goes to sleep. The insurance company then tells you who to go to realize and maximize your coverge benefits, or even if you can go outside that Network.

Answer: Yes. If you can afford it, purchase a Medicare Supplement Plan F ( if you turned 65 prior to 01/01/2020) or next best a Plan G, and pair either with a stand alone PDP( Prescirtion Drug Plan).

Answer: Helping folks and assisting them in avoiding costly mistakes, which happens often and can happen easily.

Answer: Covered, but how and for how long is dependent of where and what type of mental health services you are receiving. If therapy is ocurring in a hospital setting, usually Part A of Original Medicare will apply, if outpatient, generally Part B of Original medicare will be the payor.

I am purposely avoiding the word "fully", because each Original Medicare part has its own benefit configuration that applies, and I do not wish to assume any supplenetal plan that mitigates those out of pocket costs.

Answer: The general answer is yes, but let's drill down a bit because each preventive screening has its own timeline.

As an example, Colonoscopies are usually covered under Part B of Original Medicare. The way the charges will be covered is a bit involved, as the procedure is both diagnostic and therapeutic. It also matters where you have the procedure conducted, in a hospital outpatient setting( more expensive) or an ambulatory surgical center( less expensive).

For this procedure, the timeline is as follows, depending on whether you are a high risk for colorectal cancer, then it is once every 24 months or if you are not, then it is once every 120 months. Based on the results of a previous flexible sigmoidoscopy, it could be every 48 months.

Answer: Happy to confirm that it is not just talk. For 2025 it did happen and is happening. For 2026 it was increased to $2,100.

Answer: The answer to this question has several moving parts, and demands careful consideration.

Generally speaking Medicare does cover certain clinical trials and experimental treatments, but only unders certain conditions.

In my Medicare insurance practice I have dealt with clients undergoing monoclonal antibodies for the treatment of early onset Alzheimer's disease, this treatment is covered.

Regarding routine costs associated with a qualified clinical trial, those would be covered.

Things like doctors visits, hospital stays, lab tests, and other standard medical services that normally would be "Medicare allowed expenses' that you would normally receive even if not participating in a trial, those would be covered. Treatment of side effects or complications from trial participation, would be covered as well.

On the other hand, other research-only items, and investigational treatment or devices would usually not be covered. Exceptions might apply.

Check with your trial sponsor if the trial you are about to sign on to is a Medicare-approved clinical trial. or call 1-800-MEDICARE also visit www. medicare.gov

Answer: Yes to manual manipulation of the spine by a chiropractor to correct vertebral subluxation which happens when the spinal joints faile to move properly, but the contact between the joints remains intact.

This is covered under Part B so you first havee to meet the deductible(changes every year) and then are responsible for the remaining at 20% of the medicare-approved amount.

much your tew

Medicare does not cover other servicesor tests a chiropractor might order, including x-rays, massage therapy, and acupuncture.

Always ask your doctor or healthcare provider how much your test, item, or service he/she is recommending will cost, and what actually will Medicare cover.

Answer: Maybe. There is no one-size-fits-all answer to this question. It is all a matter of budget and individual circumstances.

I have some customers with 10 million dollar houses in gated communities, and the gaps in Original Medicare, even in large claim scenarios, might put a slight dent in their finances.

For most of my middle class book of business, having to pay the gaps in Parts A and B, might spell financial ruin.

If you go with a Medicare Advantage substitute to Original Medicare, make sure to have your agent check your providers and medications first. If you can not find your providers, go to the next plan.

Another alternate is to keep Medicare as the primary payor and if your finances allow, think of purchasing a Medicare Supplement plan and pair it with a Prescription Drug Plan.

Answer: It does not affect your current Medicare plan per se, in that if you have a Medicare Advantage plan there is no medical underwriting, but there might be consequences regarding your treatment and overall health wellfare steming from your change in medical condition as it is covered in your current plan. So it depends.

Here is what all these means, your new medical status requires the services of a provider not In Network for your current Medicare Advantage PPO or HMO plan. You need to look for a plan, during either the annual Open Election Period or the Medicare Advantage Open Enrollment Period, and look in for othe Medicare Advantage Plans directories to look for that specialist.

A word of caution, Medicare Supplement plans outside of their IEP, are mostly medically underwritten so they might not be an option to make a change.

Answer: My close to 20 years of experience helping Medicare recipients. My training and knowledge.

Every year I must recertify myself by taking Medicare knowledge and training courses and passing exams.

This coupled with real life cases of assisting clients in plan selection and assisting in resolving issues some of which are fairly involved and that resulted from bad choices taken by my clients because they did not know any better and had at the time, no professional assistance. Usually a bad idea that many times can turn to be very costly.

i also subscribe to many informational services that keep me current and relevant in my knowledge and research options.

Answer: Yes, but. Here the outmost care needs to be deployed in plan selection because provider participation is , in most cases in this scenario, challenging at best. Many doctors and healthcare institutions will not accept being In Network where you maximize cost savings and altogether avoic balance billing.

My recommendation is a Standard Medicare Supplement plans paired with a Prescription Drug Plan. Chose the Medigap letter plan that your budget allows.

Answer: No. Original Medicare Part B covers "medically-necessary durable medical equipment( DME), things like wheel chairs, hospital beds and such. A medical alert system is usually considered a safety or monitoring device, not a medically necessary piece of equipment.

Having said this, there are some Medicare Advantage( Part C) plans, rather than Original Medicare, that do offer coverage for this item. Some of these plans may offer these systems either free or at a discount.

You must check carefully the plan's benefit with your agent, as this coverage, if offered, varies widely among companies.

Answer: These are plans that cater to a very special class of Medicare beneficiaries with chronic conditions as defined by CMS, the Federal agency that regulates Medicare. Many of these fellow Americans are people with dual eligibility or DSNPs which signifies that they are eligible for both Medicare and Medicaid.

Answer: The Medicare trained and certified agent has acquired not only technical knowledge about Medicare but just as important, a familiarity with available resources to better assist customers.

If you believe that more often than not knowledge is power, then working with a trained and certified agent is a no brainer. All Medicare mistakes are costly, many much more than others.

You should always deal with professionals.