Ron Cronwell, Medicare Insurance Agent

Answer: Medicare is a federal program, so the policies are the same is all the states. If you are looking at more than original Medicare, the each state has varying policies. Such as Medicare Advantage plans and Part D plans. Also, Medicare Supplements are state controlled as to price.

So much of the analysis boils down to the individuals situation.

Answer: Generally yes. But first check the formulary of each plan you are considering to make sure it is in the formulary. Second determine the copay for that tier value. Third, if you have not been on a Part D for more than 63 days since you were first eligible, there may be a penalty that has accrued.

Check with a local agent about these questions to determine the overall cost, premium, copays, potential penalty, before moving ahead with enrollment.

In 2025 there is a maximum out of pocket limit of $2000 annually. So a very expensive drug may be more affordable with a Part D plan.

One other item, check to determine if the person qualifies for what is called Extra Help With Prescription Drugs.

Answer: Burial contracts where the owner is the funeral home do not count into assets.

Another option is to have her give the car to a underage grandchild, then the parent can dispose of the auto and use the funds to help out the mother as needed. Talk to a qualified tax professional to determine the actual process and implications.

Answer: yes. As long as the qualifying condition of income continues the IRMAA surcharge will continue to be added to your monthly premium.

Answer: Not completely. There are deductibles and copays for transactions under part A and part B. In addition there is a monthly premium for part B of at least $185 per month.

Answer: Generally NO. There are two exceptions. One is being diagnosed with Kidney failure. The other is being diagnosed with ALS.

A third is being diagnosed with Diabetes, Chronic heart failure or Cardio Vascular Disease.

Answer: Selecting a plan only based on a monthly premium. A person should consider personal situation, health, premium, deductible, and current prescriptions.

Answer: The largest mistake is usually not taking the time to get help in understanding the pros and cons of Medicare and the options when first enrolling. Find a local agent to work with to become an informed buyer.

Consider the several steps and considerations, personal health, plans available, financial situation, prescription requirements.

Answer: Most Medicare Advantage plans list in the benefit summary what the lab work copays are. Usually they are a zero copay. But check with the benefit summary to make sure.

Answer: Generally there are only a few typical costs for a chronic condition like diabetes.

1) 2 to 4 PCP visits per year.

2) If on Insulin, a $35 copay per prescription. 12 times 35.

3) Blood sugar monitoring supplies. Test strip, lancets, and meter. Many Medicare Advantage plans provide for those supplies at a zero copay.

4) If taking a prescription drug instead of insulin to control blood sugar, Then look to the RX plan and what the copay is for the script and calculate the annual cost.

Work with a local agent to help estimate the annual costs.

Answer: Under most Medicare plans, the annual Preventative Care visit has a zero copay. But the visit is not what we used to identify as the annual physical. So, if the patient request tests beyond the scope of the Preventative Care visit, there may be a charge.

If a person has 2 PCP visits a year, the second would have a charge or copay.

Answer: The changes changes in plans will be finalized and published by October 1, 2025 for the 2026 plan year. Each year in late September or early October, each plan provider sends out to current enrollee an Annual Notice Of Change document. In the document is a comparison of the current year benefits to the new year benefits.

Another way to obtain the same information is to contact a local agent and have them review your plan and your situation, help you determine if a change in plans is warranted. Some agents host Medicare seminars or host resource walk in locations, stating the October 15th, where you can obtain new year plan information.

Answer: Medicare Part D are prescription drug plans. The plans are offered through private companies and approved by Medicare and the state. The drugs covered are for chronic illnesses. Many of the drugs are available for a copay that is lower than the street price of the drug.

Answer: Usually a change in medical health condition does not impact your plan. The exception might be chronic kidney failure or ALS.

In terms of reconsideration of your plan, each year, in the fall, people with Medicare Advantage plans are able to compare plans and make changes if they wish.

Contact your local agent and discus the changes to determine how your plan covers your new situation.

Answer: Being obese in itself does not qualify as medical necessity for Medicare to cover surgery. Many Medicare Advantage plans offer free or greatly reduced exercise memberships where there are employees to help with weight loss planning exercise and meal programs. Original Medicare does not offer weight loss programming.

Work with your doctor on weight loss regimens.

Answer: That is a good question and the answer lies in a proper analysis of a persons health, financial situation, and life style. Medicare Supplements can provide significant peace of mind around medical costs. But at the same time, a solid financial evaluation of the increasing premiums due to changes in age and inflation, with affordability across time.

Also adding in the with the Supplement, a standalone prescription drug plan is needed at an additional premium.

Both Medicare Supplements and Medicare Advantage plans are positive methods to help offset the costs of medical coverage. But each has pluses and minuses that then need to be factored in with person health history adn finances.

Answer: When evaluating plans there are several points to consider. One is the monthly premium. Two is looking at the copays for various benefits. Three is weighting the possible use volume for each benefit.

An example is a low premium might include a zero copay for a Primary care visit, but have a $30 copay for specialists. So if there are two primary care visits each year that represents a zero copay. If there are three specialists involved and each is visited twice per year that represents $180 in copays.

This should not be a surprise if your agent reviewed your personal medical situation and ran a few what if scenarios to help you understand how each plan works and that is one of the strengths of having a local agent over just some call center.

Answer: If your income dropped low enough you might qualify for Medicaid or a level of Medicare Savings Program where the state would pay your Part B premium. Contact your state Medicaid office to get more information.

While investigating Medicaid, ask a local insurance agent to help you apply for Extra Help With Prescription Drugs. LIS is a income limited program through Social Security.

Answer: There are two primary types of Medicare Advantage Plans. 1) HMO and 2) PPO.

For the HMO type, those plans have a list of in-network doctors and medical facilities. Under the HMO style an enrollee is required to use an in-network doctor or facility to get coverage. Going to an out 0f network providers mostly results in the enrollee paying out of pocket for the services. For HMO's the service area can be nation wide, or reduced down to a county or few. Check with each plan for specifics.

For the PPO style of plan, it has both an in-network provider list and an out of network copay list. Using the in-network providers generally have a much lower copy than going to an out of network provider. The areas of coverage also can be different. Usually one can go to any provider that takes Medicare and they will take a PPO as out of network. Again, check with the individual plan to determine specifics.

To get the best help, find a local agent you are comfortable with and have them address your individual situation.

Answer: The would be nice, but Medicare law does not consider DVH a health related mater. CMS has been encouraging Medicare Advantage plans to offer DVH and many plans do offer DVH as non medical benefits.

Answer: The answer is no. As Medicare is a federal plan and Marijuana continues to be restricted under federal law, Medicare does not cover it.

However, one can always appeal and ask for an exception through a physician.

Answer: Since you are receiving Social Security payments, you qualify for an automatic enrollment in part A and Part B of Medicare. You should receive your Medicare card about 2 months before your birthday month. The effective date should be the first day of the month in which you turn 65. The exception is if your birthday falls on the first of the month, then your Medicare effective date is the month before.

If on disability you already have a Medicare card with A and B, the you have a special enrollment option begin again.

Answer: The coverage gap was eliminated beginning with the 2025 plan year. But in answer to your question for last year's plan, yes, Part D copays counted towards the gap dollar limit.

Answer: There are many factors that should be considered before making the selection decision. A person's health, cost, available medical services in the area, the formulary with the plan, the in-network list of the plan.

Also consider the short term financial impact and the long term impact. Do premiums rise over time?

It is a best practice to find a local agent you are comfortable with and work with that person to review your situation and look at available options. Cheap is not always the best option.

Answer: Slowly. Until CMS determines such devices are reliable and have a high degree of accuracy, and are more than nice to have, the extra cost to Medicare will probably not be approved. If, such devices can demonstrate a cost reduction to Medicare approval is unlikely. Also, the communication vehicles will need to be more universal and not vendor specific.

Answer: Nothing. But most employer plans require a member to sign up for Part A when eligible. There is no additional cost or premium to the member for enrolling in Part A. But during the enrollment in Medicare select to defer Part B. Part B is the one that has a monthly premium.

When losing employer insurance, contact Medicare and enroll in Part B. There is no penalty since you have had compliant employer insurance.

Answer: Speak with a licensed and knowledgeable local insurance agent who will you take into account your specific situation and coverage needs. The decision is not only a financial one. Family health history, your health history, peace of mind, financial, availability of medical services in you area are a few of the consideration that go into making a educated decision. What is great for another person in a different location may not be the same for you.

Answer: Medicare is a national or federal program. The cost structure is set nationally. The Part B and Part D surcharge is income based. If you have Medicare Part B and/or Medicare Part D prescription drug coverage, you could owe a monthly surcharge based on an income-related monthly adjustment amount or (IRMAA). These surcharges apply to enrollees in Original Medicare and Medicare Advantage plans.

The 2025 IRMAA income brackets and Parts B and D surcharges have been announced. This year, 2025, Medicare beneficiaries with income over $106,000 (for single tax filers), $212,000 for joint filers and $106,000 (for married people who file separately) will pay the surcharge. For these beneficiaries, total Monthly Part B premiums will range from $259.00 to $628.90.

Social Security makes the surcharge calculation based on your Modified Adjusted Gross Income (MAGI) from two years ago.

Answer: The Part A and Part B annual deductibles are set by CMS. So, they may change each year. CMS annouces what the adjustments are around mid year, for the next year.

Answer: Yes, as long as they are licensed and appointed in your state. But a local agent may be more familiar with local doctors and services available to you.

Answer: Check with the Customer Service for your provider. Another method is to check with your local insurance agent. They usually have access to a list. You may also have access to an online insurance account. Many or these provider accounts have links to dentists, doctors, and other medical services.

Answer: If you mean pay taxes on receiving Medicare benefits, the simple answer is NO. However, if a person receives payments that are may more than the out of pocket cost of the medical expense, that may be taxable. Best to check with an accountant or tax attorney.

Answer: Just follow the application questions. They are clear and precise. Do not overthink the questions. If you have significant questions, contact Medicare to clarify or visit a local Medicare office, where they can assist with the application.

Answer: Stay informed. Each year Medicare sends out a Medicare and Me booklet which explains Medicare coverage, review your copy. Also, each year providers issue a NOAC or Notice of Annual Change in their plans. Review your copy and take note of the year to year comparison.

Finally, speak with a trusted local agent about your situation and insurance needs.

Answer: So far, I am not aware of significant changes to the (LIS) Extra Help With Prescription Drugs program, other than the annual or inflationary increases in premium coverage adn copays for drugs.

Answer: Digital Therapeutics may be covered under original Medicare, but on a case by case basis. Medicare Advantage Plans also on a case by case basis.

According to "HealthCare Brew" A history of challenges

This latest development is a long time coming.

The FDA cleared the first DMHT for market, Pear Therapeutics’s reSET, in 2017. But in April 2023, Pear declared bankruptcy and reSET, plus its opioid use disorder program reSET-O, were sold to digital treatment provider PursueCare. In a LinkedIn post, Pear’s former CEO partly blamed its collapse on payer denials.

In September 2023, Akili Interactive—a digital medicine company that created an FDA-authorized prescription video game to treat ADHD—abandoned the prescription model after hitting roadblocks from payers, and offered its video game-based treatment over the counter.

These new codes may get more payers on board, Andy Molnar, SVP of industry affairs at trade group American Telemedicine Association (ATA) and head of digital health at advocacy arm ATA Action, told Healthcare Brew.

“We’re in such a better place now in 2025 than we have ever been before,” he said, explaining that now it’s possible to “actually start to show real-world evidence and cost data” to convince Congress to further expand coverage.

The Medicare test

So far, seven apps qualify for CMS’s HCPCS codes, according to the DTA:

Big Health’s SleepioRx for insomnia and Daylight for anxiety

Otsuka Precision Health and Click Therapeutics’s Rejoyn for depression

PursueCare’s reSET for substance use disorder and reSET-O for opioid use disorder

Nox Health’s Somryst for chronic insomnia

Curio’s MamaLift Plus for maternal mental health

But even with Medicare coverage, challenges remain.

Check with your professional and the insurance provider.

Answer: Under Original Medicare much of the cost is covered by Medicare. If the surgery is done in a private outpatient setting the Part B annual premium, plus a 20% coinsurance for the balance.

The person getting the surgery is also eligable for a zero cost pair of glasses after the surgery.

Answer: Here are three ways to help with an answer:

1) Call the customer service number on the back of your prescription drug card or Medicare Advantage plan card.

2) Each provider has a web sight where a client can lookup the drug to determine coverage and copay.

3) Contact your agent for assistance.

This assumes the drug is for a chronic condition and administered my you and listed under Part D.

If the drug is administered by the doctor or in the hospital, that is probably a pert B drug. Call your provider for clarification.

Answer: Medigap policies are by design and contract automatically renew each year, as long as the monthly premiums are paid on time. premiums may change form time to time. Most increase at least yearly. A provider may decide to exit an region or state, if that occurs, that notice activates a Special Enrollment Period of time during which impacted clients may sign up with another provider using a guarantied issue right, meaning no health questions. The price may be different, but no health questions and no pre-existing condition exclusions. This may happen during the year or at year end.

Answer: Most private hospitals accept original Medicare and Medicare Advantage Plans. But hospitals sign contracts with each provider company and list which Medicare Advantage plans are included. Toward the end of the contract period, if a new contract is not signed hospitals and providers are required to notify users of the hospital that the hospital may not be in network for the next period... usually the next year. Most of the time contract negotiations are completed and the hospital remains in network. But it is up to the individual to double check, before surgery or a procedure, that the hospital is in network.

Answer: The Annual Notice of Change booklets start arriving in the fall, late September through the first week of October. They usually are printed on thin newsprint paper and Have ANOC on the cover or first page. For Medicare part C and D, each person receives their own. For Marketplace (ACA) insurance, one copy is sent to the primary name on the policy.

Answer: Yes, each insurance company will send or email you an ANOC each year in the fall, usually the end of September or first week of October. This provides you with a comparison of this years benefits and price to what is offered for the next year. So you have the opportunity to review and compare before speaking with your agent with questions and advice.

Answer: I enjoy translating Medicare language into everyday understandable terms. Being an agent, I have the opportunity to help fellow seniors with insurance solutions to their health care needs. As an agent it is more than the initial sale, it is also how available I am to provide customer service and for questions.