Ryan George, Medicare Insurance Broker

Answer: It's not. They work in unison. What the question is more likely referring to is, why do people say Original Medicare is better than Advantage plans.

We actually have a cost by cost comparison of this question in all of our slides that we use for seminars. In extremely rare cases is Original Medicare "better" than Advantage. With Original Medicare you owe 20% with no cap throughout the year. IE. surgery on Jan 1 costs 100k and complications from said surgery on April 3 cost 50k, you're on the hook for 20% of those two bills, without a cap in sight for the duration of the year.

What people mean when they say "better" , things are approved quicker or not as much headaches with Original Medicare only. Again, very rare cases (if ever) does only Original Medicare make sense.

Answer: Technically no, if you have 20 or more employees at your work/on group plan, that's considered qualified coverage and you won't have a late penalty. HOWEVER, we always say don't be lazy and at least sign up for Part A ONLY. That way when you go to "turn on" Part B, A is already established and you have a Medicare Beneficiary Identification number (MBI). We say whatever is best/cheapest is what you should have if working past 65. If anyone tells you any different, that's just not true. Check with a local, reputable brokerage that specializes in health insurance and Medicare, they'll be able to guide you properly.

Answer: Usually yes. BUT it does depend on what kind of recovery care you need and where you get it.

Hospital stay after surgery:

- If you're admitted as an inpatient, Part A covers your room, meals, nursing care, and medications during the stay. You'll owe the Part A deductible ($1,736 per benefit period in 2026), and after 60 days there are daily coinsurance charges.

Skilled nursing facility (SNF):

- If your doctor sends you to a skilled nursing facility to continue recovering say, for physical therapy or wound care. Part A can cover up to 100 days, but only if you had a qualifying inpatient hospital stay of at least 3 days first. Days 1–20 are fully covered. Days 21–100 have a daily copay.

Home health care:

- If you're homebound and need skilled nursing or therapy at home, Part A or Part B covers it at no cost to you, as long as a Medicare approved home health agency provides the care and your doctor orders it.

Outpatient follow-up:

- Doctor visits, physical therapy, lab work, and durable medical equipment (like a walker or wheelchair) fall under Part B. You'll pay 20% of the Medicare approved amount after meeting your Part B deductible ($283 in 2026).

What Medicare won't cover:

- Long term custodial care (help with bathing, dressing, eating) isn't covered if that's the only care you need. Same with 24 hour home care or meal delivery.

One important note: if you have a Medicare Advantage plan or a Supplement, your out of pocket costs will look different, and often much lower. That's worth a quick conversation so we can map out what your recovery would actually cost based on the plan you're on.

Answer: Short answer: both.

And that's where it gets frustrating.

Your doctor decides what care is medically appropriate for you. They examine you, know your history, and recommend treatment based on what they believe will help. Your insurance company decides what care they'll pay for. They look at your plan's rules, their coverage guidelines, and whether the service meets their definition of "medically necessary."

Those two answers don't always match. Your doctor can recommend an MRI, a specialist, or a procedure, but if the insurance company decides it doesn't meet their criteria, they can deny the claim or require you to try something cheaper first. That's called prior authorization or step therapy, and it's more common than most people realize.

Here's the part folks miss, a denial isn't the final word. You have the right to appeal, and your doctor can submit documentation to fight for the care they recommended. Plenty of denials get overturned when someone pushes back.

So who's really in charge? Your doctor decides what you need. Your insurance decides what they'll pay for. Your job , and ours, as your broker, is to make sure those two line up as often as possible, and to fight when they don't.

Answer: Medicare has actually been moving this direction already!

Acupuncture for chronic low back pain was added in 2020, chiropractic has been covered for years, and many Medicare Advantage plans now include acupuncture, chiropractic, and fitness benefits as supplemental coverage. The real question isn't "alternative vs. conventional" but whether a treatment has solid evidence behind it.

Answer: Some brokerages have the ability, in real time, to put your meds into the system and get pricing on them. There's always some things you can try to do to get the brand cost reduced, however in general terms, the maximum out of pocket in 2026 for Part D/Prescription drugs in $2,100. Again, could be some speciality meds that fall into Part B, but for sake of this question, just know once someone hits a total of $2,100 of out of pocket cost, they're done for the year.

Answer: Hard to say, it depends on the situation and what plan you're on.

Part C/Advantage, has a standard appeal of 30 days. Expedited can be as quick as 72 hours, with a continuation of care being requested while appeal is pending.

Part D/Prescription Drug Coverage, has a standard 7 day redetermination period. Expedited, same 72 hours as Advantage. For an IRE (Independent Review Entity), 7 days or 72 hours.

Part A & B/Original Medicare, redetermination is 60 days to decide. Reconsideration is also 60 days. Medicare appeals council is 90 days.

Best rule of thumb is to get the appeal over ASAP and let them worry about the deadlines. If you're looking for a general timeline, stick to 60 days from the denial letter is the latest in which you can appeal.

Answer: You can, but the answer you're looking for is in the cost. Typically, Part A is free if you or your spouse have 40 quarters or 10 years of U.S. work history. If you're under that amount, you'll be paying. Either $278 (in 2025) or $505 (in 2025). Part B is usually a purchased benefit (depends on income), so work history overseas doesn't affect Part B eligibility. In short, Medicare is available, but can cost more based on work history.

Answer: Your moms fear is correct. Not because Advantage plans are bad, quite the opposite, they can be great! However, no one should choose a Medicare plan based on what their friends have. For your mom, I'd have her (or you) reach out to a local brokerage, that can help answer any and all questions. "PPO" gives her greater flexibility with doctors than an "HMO", but talk to a local professional for a better understanding. If you or her are adamant about checking on your own, once you have a plan chose, call her doctors and ask "if they accept (whatever insurance company) Medicare plan". Important to say Medicare plan.

Answer: If you truly understand the in's and out's of Original Medicare, as well as Part C/Supplement plans & Part D, then no. However it doesn't cost more to get information, as a matter of fact, it's free to you. There's no downside in talking to a broker with access to all the plans in your area. All brokers get paid the same regardless of premium, so it's not as if they get paid differently based on the premiums like other insurances.

Answer: Nope! Some people think it comes from the Medicare tax that you've paid in to your whole life, but in reality, that isn't technically true. CMS (Center for Medicaid/Medicare Services) pays each Medicare Advantage plan a fixed rate per enrollee. They're essentially funded by the insurance company operating more efficiently than what they're supposed to by CMS guidelines.

Seems fishy, but they're just trying to entice you to use their company!

Answer: You can! You need to check with your provider/preferred hospital network to make sure, but as long as they are in network, you can continue to see them. Just be sure to remind your doctor, pharmacy, etc. next time you see them.

Answer: Better, no. More suitable to your needs, yes.

Advantage plans come in all shapes and sizes, but they also are based off your home residence zip code. If your relative that lives up the street, lives in a different zip code, they would/could have access to different plans.

We always say everybody is different, not in terms of needs, but finances, location, health, etc..

You should never pick a plan because someone else already has it and it's worked for them.

Answer: Sometimes people accidentally use the word "deductible" interchangeably, however for this question we'll go off the true meaning.

Every year your deductible resets, similar to your individual insurance when you had it, either through your employer or on your own. The government likes to make Medicare more confusing than it needs to be. At the end of the day, Medicare is very similar to the insurance you had pre 65.

Answer: Common question! Insurance companies receive fixed monthly payments from CMS (Center for Medicare/Medicaid Services) for you. The government redistributes the money it would have spent on Original Medicare coverage to the Advantage insurance company.

All stuff that happens behind the scenes.

Answer: You are in what's known as your Initial Enrollment Period (IEP), you have the 3 months before the month of your birthday, the month of your birthday, and the 3 months following the month of your birthday to get on to Original Medicare (A & B). If you have what is known as "qualifying coverage", your IEP is different. However, first step you would want to take is contact your local Social Security office, via phone, online, or in person. They'll get the process started for Part A and Part B and explain how it works with Social Security and SS benefits.

Answer: Short answer, no. Not fully anyways. Part A covers limited stays in a Skilled Nursing Facility (SNF) if you require specialized rehabilitative care following a qualifying hospital stay.

For long term care, for assistance with daily activities such as bathing or dressing, that's handled by Medicaid, long term care insurance (LTC), or private pay aka you pay yourself.

Answer: Mind their own business!

Kidding... Not every plan, Supplement or Advantage, are right for everyone. Even spouses will have different plans. There is no right answer when it comes to Medicare in terms of one size fits all. It changes based on health, plans, needs, finances, location, etc.. Can even change based on years.

Answer: Great news! At the time of this writing, in 2026, the donut hole is no longer applicable! If you are reading this in 2025 and beyond, you're good to go with no donut hole!

Answer: You can! However, you'll have to go through medical underwriting, which you can be denied coverage at that point. Doesn't mean you'll be canceled off the plan you're currently on, but after your Initial Enrollment Period, you have to be approved to change Supplement plans. Even if you're going from same carrier, just to a different plan, still need the underwriting questions answered.

Answer: Absolutely! We do it every day! As long as we have the plans in that area that best serve the clients, you can deal with any brokerage you so choose. The one thing to make sure of, is that you're not only getting guidance from one insurance company, try to find a broker.

Answer: There are! You can always go in person and chat with the local SS office to get more of the answers you're looking for.

Answer: As long as you have qualifying coverage, aka group insurance, individual insurance, etc.. no you will not be penalized. BUT if you do not have that coverage and miss your Initial Enrollment Period window for Original Medicare (Part A & B) and Part D, yes you can have a penalty. We always tell everyone, they in most cases, give you 7 months to enroll, don't be lazy!

Answer: The biggest mistakes seniors make when choosing Medicare, is two things.

1. You get into a plan because your friend, neighbor, spouse, coworker, etc. has it.

2. You don't talk to a local brokerage that can give you access to all the plans in your area.

Answer: When you first turn 65 (or are new to Medicare i.e. got off employer plan and retired past 65), you have what is known as your Initial Enrollment Period aka IEP. During this time you are able to get into any plan you should choose without worrying about pre-existing conditions. Once your personal IEP is over, you have to go through medical underwriting to change Medigap/Supplement plans.

Answer: Annuities can be a huge part of your financial picture, especially as you age. That's why we partner with annuity experts whose sole job is to find you the best annuity plan for you.

Answer: We had a client that was on a very rare, and expensive, drug. However, her premiums for her plan were outrageous, price wise. She wanted us to move her to a different Advantage plan, but the problem was she was on a group Medicare plan via her husbands employer. That plan was a union worker plan and it made her rare drug be free. So ultimately she needed to stay on the high premium plan to ensure her drug was covered.

Answer: Answer is simple, if you work with a local BROKER, they'll be able to represent (should anyways) all the carriers and plans in your area. They'll be able to pick up the phone any time and help without having to call n 800 number. You'll also get someone that is unbiased in terms of what carrier they benefit from, because in Medicare it's all federally regulated.