Steven Bleicher

What's one piece of advice you wish every senior knew before picking a Medicare plan?

Answer: THE most obvious knowledge as a newbie to Medicare is that the most expensive plan isn't necessarily your best choice. It has a lot to do with your potential health issues, how well you get along with your Primary Care physician (does she/he give you the bum's rush), the drugs that have been prescribed, as well as how your finances are at the time you apply for Medicare. Steve

How do you educate clients who are completely new to Medicare?

Answer: Since I've been a Medicare expert for years and voluntarily teach Medicare at the local university for both those new to Medicare or those who are already in Medicare but wish to take a refresher course based on the new calendar year with the inevitable $$ changes. Thus, I email prospects all of the digital files that I have developed for my classes in advance of visiting them or speaking with them over the phone.

What role do you think technology will play in the future of Medicare?

Answer: Based on the innovations in the digital world, this existential question will constantly be asked since not only will Medicare itself continually change but so will AI be teaching people in a more simplified way.

What does Medicare Part B cover? Is it enough?

Answer: Medicare Part B covers 80% of the cost when you visit your doctors, have your blood drawn, having needed to obtain physical & speech therapy when an accident or health incident has occurred. The 20% "coinsurance" balance is then covered by a Medicare Supplement plan to its fullest extent and an Medicare Advantage plan to a decent but lesser extent. It should cover enough of the cost especially since seniors do obtain an inflation percentage increase to cover the cost of living from the prior year.

I'm retiring next year - do I need to do anything with my Medicare?

Answer: If you've been happy with the coverage since you turned age 65 and applied for Medicare, then most likely the ONLY aspect of healthcare to review each year surrounds the Rx's that have been newly prescribed OR those which are Brand Name drugs (Tiers 3, 4 and 5) for which the global economy has adversely affected its cost from one year to the next. Please remember that a Part D(rug) plan may be your best choice in one year but not necessarily as good for you in the subsequent years. NOTE: Please read your "ANOC" or the Annual Notice of Change which is mailed to your home every late October/early November. Steve

Why is regular Medicare better than an advantage plan?

Answer: There is actually no such thing as "Regular Medicare". People know that there are two options when one turns age 65: A) a Medigap, also known as a Medicare Supplement and, B) a MAPD, a.k.a., as a Medicare Advantage Plan (with drug coverage). There is no cookie-cutter answer to choosing one over another since one's finances come into play, along with any potential health history of the applicant and her/his family history for "co-morbidities". If your parents lived a long life, that usually means you're ahead of the game, if you will. The major difference with an Advantage plan is though there is no monthly premium for this plan (since it is govt-subsidized), the give & take is that each MAPD has a steep deductible which you are responsible for which renews every single year. The dollar costs for these plans are dependent upon our global inflation. The Medigap, with a monthly premium has no deductible except for the one-time/year Part B $257.00 deductible. Each and every deductible will be likely to change at the new calendar year. Remember: an MAPD Advantage plan usually includes your drug coverage, whereas a Medicare Supplement plan has nothing whatsoever to do your prescriptions. That's what a "Stand-Alone" Part D plan is used for.

What do you enjoy most about working with Medicare clients?

Answer: Easy one. In coming from a family of teachers and with no two Medicare-eligible prospects are totally alike, I enjoy my ability to instruct the candidate about the quirky aspects of Medicare. Plus, there is NO "cookie-cutter" answer to clients about which program is the best for them. It must be evaluated based on health issues, finances and the Rx's being taken, among other things.

Do I have to answer health questions when switching from one Supplemental/Medigap plan to another?

Answer: If a full year has passed after turning age 65, there will be a series of health questions which must be answered in order to change your Med. Supplement plans. If you've remained healthy, the odds are good that a change will be approved. However, please note if you are still WITHIN the one year period of obtaining a Medigap/Suppmt. plan, you will have a right to change companies without having to answer any health questions. Thus, acclimating to your plans initially, no matter what they are, is paramount.

How will the new 2025 Medicare Part D out-of-pocket cap impact seniors and prescription drug costs?

Answer: This year's out-of-pocket expense is set at a maximum of $2,000.00 (last year it was $8,050.00!). Those folks with heavy duty Brand Name drugs will be paying no more that the $2K amount for every single drug that they are prescribed. However, with some expensive drugs, be aware that though you have the right to purchase drugs from either a US or Canadian online pharmacy at discounted rates, those bought from Canada will NOT be applied toward the $2K max out of pocket amount.

What is the biggest mistake seniors make when enrolling in Medicare?

Answer: Thinking that their drug costs before Medicare will resemble those same costs when joining Medicare. It is imperative to realize that Medicare drugs are priced much differently than those you enjoyed as part of an employer's healthcare plan. Brand Name drugs will be a greater challenge especially any drug in Tiers 3, 4 and 5.

Who can help me figure out this Medicare "maze and alphabet soup" it's so confusing.

Answer: Not only am I a volunteer instructor of Medicare at the U of A in Tucson but am an independent agent who teaches my peers at their homes or over the phone by sending attachments to their email addresses prior to the arranged “visit”.

What do you like most about being a Medicare agent?

Answer: Having the opportunity to teach my peers all of the quirks of Medicare has forever been my goal. I am paying it forward in that back in NYC, after moving to Tucson, my mother developed a # of major health issues. I feel that strangers came to her aid and caused her 7–8 more years of life until she passed at 92. This was my motivation to branch out into the healthcare field from scratch as the job I had back East simply didn’t exist here.

What additional coverage options are available for international travelers?

Answer: Some options in Medicare include overseas travel. For instance, with a Medicare Supplement (a.k.a., Medigap), the 1st 60 days of any trip is covered with any health ailment affected by a natural cause or by a serious accident.

I've got a Medicare Advantage plan, and I'm curious if my upcoming eye surgery is fully covered or if I'll owe extra out of pocket.

Answer: Bear in mind that there are over 60,000 treatments that are covered by a government subsidized Medicare Advantage plan, being your Primary insurance at 80%. The rest of the money or 20% is paid by Medicare itself, your Secondary insurance. However, some things written in the policy may not be completely covered. Your doctor should know that! This is the “give and take” since you’re responsible for a somewhat steep deductible since you likely have no monthly premium.

What if I missed my window to sign up?

Answer: Should you miss the SEVEN-MONTH window of opportunity (before the birthday month when you're about to turn age 65) to enroll into Medicare, depending upon whether you are still working and receiving healthcare coverage from your employer, there are a number of aspects that you may encounter. So, it is imperative that you've picked up at least Part A but not necessarily Part B as yet. Call 1-800-MEDICARE to investigate your specific situation. But the longer you wait to do this, the worse it could be.

Is Medicare Part A enough for hospital coverage?

Answer: When you become eligible for Medicare (usually at age 65), Part A is totally free as long as you've worked for 10 years, contributing to Social Security, taken out of your paycheck during that time. Bear in mind that Part A (inpatient hospital admittance) will pay 80% of the charges surrounding your treatments/surgery. The other 20% is normally covered by applying to either a Medicare Supplement or a Medicare Advantage plan. However, if you're still working, it's normal that your employer is paying for your healthcare unless you're working part-time.

So, to answer your question, Medicare pays for over 60,000 different procedures. As long as yours has a dollar value associated with it, it should be enough. But if you are considering an experimental treatment, Medicare does not pay for that until CMS approves it.

Can Medicare Part D deny coverage for a brand-name drug if a generic isn't available?

Answer: There is a Medicare rule that states (I am paraphrasing this): Should your Part D plan no longer offer a particular drug, they are required to sell you a one-month supply while you search the web (both US & Canadian discount websites) for a supplier who does include that (usually Brand Name drug) in their drug formulary. If you wish email me at [email protected], I'd be glad to send you my "Drug Discount Websites" digital file which I developed for the Medicare classes which I voluntarily have taught for many years at the University of AZ, here in Tucson.

Why do doctors not like Medicare Advantage plans?

Answer: Doctors have three main reasons for disliking MA plans: A) they don't want to do the paperwork involved with these types of (free of premiums, govt-subsidized) plans, B) due to that paperwork, they would be forced to hire more people to administer the plans, and

C) Advantage plans take much longer to pay the in and out of network physicians and thus want nothing to do with any Advantage plan. But they gladly take on patients with Medicare Supplements, a.k.a., Medigap plans.

My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?

Answer: The only healthcare procedures that are NOT covered are those of an experimental nature. However, once the CDC checks out these types of treatments, as long as it meets the quirky Federal guidelines, it may be declared to be covered. Be advised that there are over 60,000 treatments that are currently covered by Medicare. Your doctor was being honest with you and the odds are that most of the "uncovered" treatments are those recommended by a chiropractor since they can (via trial-and-error) attempt to develop a procedure that she/he successfully worked with "some" of their patients. Your best double-check is always to call 1-800-MEDICARE and the reps should be able to sanction a procedure unless it is brand new and has yet to be tested.

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

Answer: In 2025, the maximum amount of $$ that any one individual will spend on drugs is indeed a Grand Total of $2,000.00. This encompasses both Brand Name drugs as well as generic drugs which Medicare keeps track of. This also entails that though folks had the opportunity in 2024 to use Canadian online pharmacies that discounted many of one's drugs, that is no longer the case this year. So you can, in effect, save money on each drug refill purchased with a Canadian pharmacy, that amount of money will NOT be applied toward the $2K annual deductible this year. This means that you'll have to figure out yourself if buying from Canada over the course of the entire year 2025, will that be better than purchasing it from a US discount website (i.e., GoodRx, costplusdrugs.com, simplecare.com, etc.)

How does getting married late in life affect my Medicare coverage or costs?

Answer: Marrying late in life won't have much to do with Medicare but with your Social Security entitlement. But those who are married for at least ten years will have choices upon retirement since Social Security's "formula" takes into account your 35 best earning years.

(Based on the rules today, Social Security can be opted to be picked up for those as young as age 62 and as late as age 73). However, when one turns age 65 or has been declared disabled by any governmental agency (either Federal or State), once 2 years have elapsed, no matter what age you are, there is a rule that you can become a Medicare-eligible beneficiary. I've had clients who were 47 years old who were approved to pick up Medicare due to their disability. The only limitation is that you can acquire only a Med. Advantage plan (Part C) and not a Med. Supplement plan. Though, the latter can be picked up upon turning age 65 by dropping the Advantage plan. You cannot have both an Advantage Plan - Part C, alongside a Med. Supplement, also known as a Medigap plan.

Should there be stricter regulations on Medicare Advantage marketing and sales practices?

Answer: I'm sure most of you will remember this: A few years ago, there were many TV commercials featuring celebrities like Joe Namath, William Devane & Jimmie Walker which initially caused a multitude of problems for seniors who were about to become Medicare-eligible. They misinformed the public and caused many people to switch to another plan when they ALREADY had the VERY SAME plan with another insurance company in their possession.

The Center for Medicare & Medicaid Services (CMS) forced these commercials to be redone and to eliminate the misleading information but still used those same celebrities as if nothing was wrong. This was a prime example of the need for greater supervision of these overly frequent TV commercials.

Moreover, there are Medicare agents who are known as "captive agents". These folks can only sell healthcare plans for one company. Therefore, it is incumbent upon you to find 2nd and sometimes 3rd opinions from independent representatives who are affiliated with various companies who can offer both Med. Supplements, as well as Med. Advantage plans. There is a wide difference between these two plans. In my opinion, it is essential to find an honest broker who can describe the major differences between those 2 plans. Moreover, the most expensive plan is NOT always the best plan. Check out the premiums along with the value of a plan's annual deductible if you're interested in an Advantage plan.

I've been dreading hitting the donut hole each year. How will its elimination in 2025 change what I pay throughout the year?

Answer: You've been happy to learn that the donut hole has been abolished. This is a great savings for people who take a variety of different drugs. There is a $2000.00 maximum out-of-pocket through 2027 matter whether you take generic drugs or Brand Name drugs. Last year, folks paid a maximum of $8,050.00 in the donut hole and it has been replaced by the $2,000.00!! Medicare keeps track of your costs for you.

Don't forget that you have options with regard to paying for a copay for a drug. These are as follows: A) Making a copay for a prescription at your "Preferred" or in-network pharmacy when you have an Advantage plan, B) if you opted for a Medicare Supplement, along with a "Stand-Alone" Part D prescription drug plan, again going to a in-network preferred pharmacy can be your best choice, except for C) using an online discount pharmacy (like GoodRx.com, singlecare.com, costplusdrugs.com, etc., which can yield a better price than thru your Part D drug plan. That is an option; but you can only use one or the other for the same drug. Also, remember that if you've had success in the use of a Canadian online discount pharmacy, those out-of-pocket costs will no longer be applied toward that $2K deductible.

I went to a free Medicare seminar and it felt like a timeshare pitch. Are any of those events actually helpful?

Answer: Though those seminars can be somewhat helpful, your best choice is a one-on-one visit with an independent agent/broker who will take your personal information into account and be specific toward your health issues, your family history and naturally, your pocketbook. With a seminar, it's a numbers game while a visit to your home or at a neutral site is more beneficial.

Are home modifications (like stairlifts) ever covered by Medicare for safety reasons?

Answer: Yes, if you can prove that the modifications were needed as a direct result of a health issue, it would be covered. You just need your doctor to corroborate your "story". They can widen a door opening to accommodate a wheel chair, as well.

My Advantage plan says I need a referral just to see a dermatologist. I thought PPOs didn't require that - was I wrong?

Answer: Just because a PPO allows you to go both in & out of your Advantage plan's network has nothing to do with referrals. You're confusing two different principles here. Also, bear in mind that I know the State of Arizona backwards & forwards. That means that there are likely some states where the answer given above may be different. It would make sense to check with your Medicare insurance company or your agent.

I missed my Medigap window by a few months and now no one will cover me without underwriting. Why isn't this rule more well known?

Answer: The first thing that comes to mind is that you probably did not meet with a long-time Medicare professional agent who knows the ins & outs of its very quirky rules. In my opinion, enrolling with Medicare yourself online means that you may be bypassing the rules concerning the different periods during the year when one can enroll AND make changes.

The only thing for you to do at this point is to enroll with a Medicare Advantage plan temporarily (you HAVE the right to do this at anytime since you've never enrolled before by picking up Medicare Part B with a monthly premium). Then, when the Open Enrollment begins on October 15th thru Dec. 7th (to become effective on Jan. 1st of the following year), you have what is known as "a trial right", meaning since you have your very 1st Medicare plan for less that 12 months, you will be able to apply for a Medigap (a.k.a., Med. Supp.) without having to answer any medical questions concerning pre-existing conditions.

Using any online information only yields the more well-known tenets of Medicare. The best advice I could ever give anyone regarding THE most important aspect of your life: HEALTH, is to be certain to get a 2nd & even 3rd opinion from an independent rep who is also known as a broker. However, in using a "Captive Agent": one who only has allegiance to one insurance firm, is foolhardy since all companies who offer Medicare-compliant Advantage plans can vary the rules to a certain extent. Though I truly hope that most agents are honest/reliable and can cover the gamut of the regulations, as an instructor myself, I will deliberately "over"-emphasize the more important areas/rules to all of my clients. Good luck and if needed, call 1-800-MEDICARE so that the person on the other end who's trained for this, confirms what a trial right means.

Is it true that Medicare pays for dental implants?

Answer: Wherever you got that idea, please cross that person’s name off your advisor list! That is totally NOT true. The only aspect of Medicare that pays anything are for routine Dental, Vision and Hearing. The reason is that when Medicare was established in 1965, the Feds wanted to only be responsible for the inexpensive healthcare treatments. For example, in the Dental area, Medicare pays for x-rays cleanings and fluoride treatment. But, if you are seeking an umbrella policy that covers the more expensive procedures, buy a “DVH” (Dental, Vision & Hearing) individual policy that covers “some” aspects of implants, root canal, partial dentures extractions, etc. Your best option is one that can cost about $65.00 per person depending on your state.

Won't Medicare run out of money before I can benefit from it?

Answer: My succinct answer is NO! Don’t listen to those “scare tactics”. I recently saw that there is enough until around 2040.

Isn't it concerning that Medicare Advantage plans are taking over the system?

Answer: All things come in cycles. That’s the key point relevant to this question. When that happens, I don’t know but it won’t be too long until people turn to a Medigap policy (a.k.a., Medicare Supplement).

I use a continuous glucose monitor for my diabetes that connects to my smartphone. Will Medicare cover this technology for someone with my condition?

Answer: Yes. “DME” stands for Durable Medical Equipment. A glucose monitor is paid for by most Medicare Supplements (aka, a Medigap plan). Go to medicare.gov and put DME in the horizontal search box. You will find that a Medigap covers over 60,000 treatments while an Advantage has a high deductible which, depending on the company, will potentially provide partial coverage for the monitor.

I keep hearing about free preventive services with Medicare. What exactly is free and what will I still pay for?

Answer: Depending on your chosen company and if you opted for a Supplement or an Advantage plan, there are 2 code #’s that a billing department person will code the treatment that was provided. If you made the appointment due to some pain you are feeling, then that is to be coded as “diagnostic” while a visit without pain is coded as “preventive”. Though, if during an annual checkup, the doctor discovers a “problem”, then the visit will change to a diagnostic code, even though it began as a preventive code. All doctor visits are covered by Medicare Part B at an 80% rate. The remainder of 20% is paid partially by the secondary insurance you have. If a new procedure has been done in a hospital, then Medicare Part A pays the 80% and the secondary again does the 20% in the same manner as above.

Does Medicare fully cover nursing home care, and are there alternatives?

Answer: No, it does not. Medicare only covers the 1st 100 days at a Nursing Home, Assisted Living and Alzheimer's facilities. To be more specific, within the first twenty days, there is no cost at all to you. Then, on days 21 - 100, it reverts to a daily rate which is $204.00 per day. If you've enrolled in a Med. Suppmt., depending upon the "letter" of the Suppmt., that is also fully paid for. But when you've reached the 100th day, Medicare drops out. The Medicare Advantage plan is different from a Suppmt. and each insurance company will vary those and its hospital benefits. If you've previously enrolled into a Long-term care policy, that should kick in on Day 101 and also will be dependent upon what benefits you had opted for within either a LTC or "Recovery Care" policy (which used to be known as Short-term care). Always remember that some states dictate their own regulations with specialty care; I can only generalize the above.

Are mental health services like therapy fully covered under Original Medicare?

Answer: Mental health is covered but it is up to you to review different company policies since they could vary widely from state to state. There is a limited number of days that should be covered. It is incumbent upon you to fully understand those limitations. This is why it is imperative to go over with a knowledgeable agent who can easily differentiate between what an Advantage plan covers vs. what a Med. Suppmt. (Medigap) covers in this extremely important area.

I need both a psychiatrist for medication and a therapist for talk therapy. How does Medicare coordinate coverage for these different providers?

Answer: This question may be a bit "iffy" as there are psychiatrists who may also serve as a therapist. Be cautious when you enroll into Medicare since there are widely different benefits between a Medicare Supplement plan and a Medicare Advantage in regard to this topic. The main thing to concentrate on would be the meds that are prescribed since there are differing types of anti-depressants with widely different copay costs. Naturally, with an Advantage plan with a network, you are forced to use those specialists within an HMO network. However, the better option likely is an Advantage plan which is a PPO since this allows you to go BOTH in and out of the plan's network. When going out of network, the costs for that option would also be higher $$. Plus, this wouldn't happen with a Supplement since it is a "non-network" plan for any type of treatment. And you won't need referrals from your Primary Care doctor.

Can you explain Special Needs Plans in Medicare?

Answer: Sure. If you are already qualified for Medicaid and are about to enroll with Medicare, you're going to qualify for a "SNP" or Special Needs Plan. This means that you are not going to pay for ANYTHING at all since your status (financially speaking) has been approved. Not every insurance firm offers a SNP plan. You will have to do a little searching but it should be fairly easy to do. By the way, if you've been granted Medicaid status by either a State or Federal agency and two years have elapsed, no matter what your age, you can enroll with Medicare! There are clients who are in their 50's who were approved for Medicaid and then 24 months later, they were able to only enroll into an Advantage plan with drug coverage. But, when you are Medicare-eligible at age 65, you can transition to a Medicare Supplement and a Part D(rug) plan, each with a monthly premium, if that is your preference.

Are Medicare plans and requirements different for every state?

Answer: Differences occur from state to state with respect to the Medicare Advantage plans. However, since a Medicare Supplement follows all CMS rules, those are sacrosanct and cannot vary without Congress agreeing to a new set of rules. This is why it is imperative to carefully review the variables between insurance companies. This also means that you should consider whether your agent is a “captive agent” (only works for one firm) and therefore cannot compare the HMO, the PPO and the SNP’s (Special Needs Plans for those with Medicaid & who are close to being eligible for Medicare), all of which are types of Advantage plans.

My plan covered my cataract surgery but not the lenses I actually needed-how do they get away with that?

Answer: These situations likely mean that you have a Medicare Advantage plan. If so, companies have the right to vary the regulations and in your case, cataracts are common and they are saving you money for the surgery, done weeks apart on both eyes. Not to be punny, but you have to treat your initial Medicare Agent interview with both eyes open. Don’t forget that the Supplement plan provides specific differences that you are going to need a number of years later than when you 1st turn 65! Do consider everything!

What's a common trick in Medicare marketing that hides restrictions on doctor choices?

Answer: I'm going to use the choices that doctors make concerning a quicker

recovery due to a new prescription. The most frustrating problem

today is the "over-use" of "PRIOR AUTHORIZATION" specifically by

your insurance company. This is NOT your doctor's fault. This is

extremely prevalent due to greater dollar restrictions nowadays.

When being interviewed by a competent Medicare agent, it is an

essential topic to discuss "P.A."! This is not something that any

agent can anticipate since it has become an overwhelming cause

for complaints specific to "MAPD" (in-Network) Advantage plans.

Be sure to recall that you have two choices with the RX copays

that are a part of Medicare: A) you can use your Advantage plan

as a means for the purchase of a drug at a "preferred" pharmacy,

or, B) you can use any US online discount website (the most

common is www.goodRx.com, singlecare.com, etc. ) which will

feature better copays for certain drugs. Moreover, their cheapest

copay also may be at a pharmacy which you don't usually use.

Thus, if it is a much better price, you must notify your doctor to

re-send this new Rx to the "other" local drug store. It is a quick

double-check with these discount online websites to fill in the

long horizontal search box on the landing page. Be certain that

you use their drop-down menus to specify the dosage and the

frequency of the drug's (usual) 90-day use.

I have severe rheumatoid arthritis and my biologic medication costs $6,000 per month. How will the 2025 Medicare Part D changes affect someone in my situation?

Answer: Greatly!! The passage of the Inflation Reduction Act last year means that the most you will spend on known Rx’s (not ones of an experimental nature) is going to be $2,000.00 which Medicare will keep track of. Bear in mind that the $6K is preposterous! This could also mean that as long as you know that a “bio similar” drug is not recommended by your doctor as a substitute, in the very 1st month, you have already surpassed the maximum out of pocket! This is going to be a boon to your expenses this year.

I picked a PPO for the flexibility, but now every time I go out of network the bills are outrageous. What's the point of even having a PPO?

Answer: This is among the many reasons why people who are still within their first year of having enrolled into Medicare that spending for a Medicare Supplement ought to be considered. Being within those 1st 12 months exempts you from having to answer the medical questions. You are entitled to a guarantee issued Supplement and the G plan, the N plan and the high deductible G plan should have been considered. Check them out now if you’re new to Medicare.

I've been diagnosed with bipolar disorder at age 66. How should I structure my Medicare coverage to ensure I get the mental health care I need?

Answer: Yes. The most obvious means toward doing that is to ask your agent what is covered in your policy in the area of mental health and those medications that are prescribed to treat that malady. If you want to compare your current plan with other companies, it is going to be essential for you to realize that mental health is covered by Medicare but only so much. This depends upon the State you live in, unfortunately. You need to call both Supplement firms as well as those who offer Advantage plans. Based on a "side-by-side" comparison, you should have enough ammunition to make a determination. It would have been better had you come to this conclusion before a full 12-months had elapsed after turning age 65. This means that now you will be subject to underwriting though you won't be declined just for a bipolar disorder but an accumulation of health issues that you might also have.

What is the trap of Medicare Advantage plans?

Answer: Prior authorization! This has nothing to do with your doctor or your agent but with your insurance company. There have been a greater # of insurance firms that now will question whether a less expensive treatment for your malady may be used instead of the first one prescribed by your Primary Doctor. Moreover, you likely know that an Advantage plan has no monthly premium as it is subsidized by the Federal Govt. As a tradeoff to that, it does contain a fairly steep deductible which again, depending upon the State you live in and the policy of your insurance company, can be a burden for those with not much money. This is why it is essential to fully understand the differences between a Med. Supplement (with a premium) and a Med. Advantage plan. The cheapest premium does not always offer the best benefits!

Remember this: at 65, you're likely to be healthier than you will be in 5 or 10 years. So, just because you may run 3 miles a day, doesn't mean that you can keep that up when you're 75!

Why am I paying more for Medicare Part B and D than my friends? What is IRMAA and how is it calculated?

Answer: This sounds like whoever you dealt with when you were about to become Medicare-eligible DID NOT TEACH you "the system" properly. Hopefully, you did use an experienced agent who was not a neophyte in the Medicare arena. IRMAA is the manner in which Medicare determines how much each Medicare member will pay for Part B (Part A is usually free). This has everything to do with your 2-year old tax return in the area of your "Adjusted Gross Income". Go to the Medicare website and put in the letters "IRMAA". This will take you to the part of the Medicare.gov site which shows you a chart.

But, first look at your 2023 AGI and if you file individually, check that column vs. if you file with your partner, look at the column called "joint" filer. That indicates how much you'll pay in the New Year. It is also based upon the global inflation factor too, of course. As far as your Part D prescription drug plan, be sure that your agent isn't a "captive agent" since that means that she/he only works for one insurance company (ergo, a conflict of interest?).

Dealing with an independent rep/broker is much better since she/he will note the drugs you take, the dosage and the frequency and use the Medicare.gov website to see which of the various drug plans in your State (Part D) are the best for you. Having been prescribed Brand Name Rx's (more expensive) means you'll be paying a higher monthly premium.

However, you also have the right to use any US online pharmacy (like GoodRx.com, singlecare.com, costplusdrugs.com, etc. ) and see if their cost for the exact same drug may be less expensive for you. But, you can use ONE or the OTHER (NOT BOTH) for the same Rx): A) your Part D(rug) plan or, B) any online discount pharmacy. Note: Be aware if you use a Canadian discount pharmacy, please consider that any drug provided by that cheaper pharmacy will NOT count toward the maximum $2,000.00/year which is the most that any Medicare-eligible person will be spending for drugs in 2025 & 2026.

Don't you think Medicare's focus on treatment rather than prevention is backwards?

Answer: I do agree. The dilemma here is that due to the scarcity of Primary doctors in the US, focusing on prevention rather than treatment (in the long run) will be less expensive to Medicare. In our global economy, this is "the formula" that healthcare has adopted. Moreover, there are two specific kinds of "codes" that are placed in your record after a visit: A) "Preventive", and, B) "Diagnostic", the latter of which will come out of either Part A (in-patient) and Part B (out-patient) Medicare, therein costing the Feds the extra money. However, when a person sees her/his doctor without complaining of any type of pain, that visit is automatically coded as Preventive, thus costing the patient more $$ rather than the Federal government. The exception to that is, for example, if you're having a colonoscopy and the surgeon removes some polyps which have to be analyzed, if it has been found to be cancerous, it will change codes from a preventive visit to one that needs further discussion and thus is now diagnostic.

Is Guaranteed Issue available after the Medicare Open Enrollment period ends?

Answer: I suggest you go to Medicare.gov and put in the search box "SEP's". This stands for Special Election periods. These represent "odd" times when certain circumstances occur which allow you to use an SEP and change your initial plan. There are numerous SEP's that folks can utilize at their discretion. The most obvious one is when you have moved your domicile to another location be it within your State OR outside your current State.

Most of the time however, "GI" or guaranteed issue are for those newly eligible Medicare folks who are within that 7-months' window of eligibility. That is: 3 months before your birthday month, your actual birthday month and 3 months after your birthday month for a grand total of 7 months.

However, folks are usually not aware of what is called a "trial right". This means that if they are inside one year of having joined Medicare at age 65, they can exercise a trial right, dropping what they initially thought was better, in favor of an alternate plan (whether it is a free Advantage or a monthly Medigap (or Med. Supplement) premium plan).

I'm homebound and need remote monitoring for my heart condition. What Medicare benefits might apply to someone in my situation?

Answer: There can be a wide variety of answers to this question due to the various symptoms that folks can have. There are tools that can be used to "remotely" signal to an outside location that your heart is working properly (or not). You will be beholden to your cardiologist who is your expert and will write up "A PLAN OF CARE" specifically for you. It might entail a number of hours a day where the doctor feels that a registered nurse ought to see you daily or every other day, depending upon the cardiologist's discretion. The other side of this coin is that I can only presume that an operation to remedy your dilemma is out of the question. It can sometimes have a lot to do with which plan you picked up at age 65 between a Medigap or Supplement vs. a Med. Advantage plan both of which demonstrate differing benefits.

I worked for the federal government for 30 years and took early retirement. How does my federal retirement affect my Medicare options?

Answer: Due to your work history, when you become Medicare-eligible, you have the same rights as those who did not work for the Federal Govt. Most folks like you have enjoyed excellent healthcare benefits during your career. You will be tasked with comparing what benefits you have retained as a veteran of the govt., vs. what you "might" gain as a Medicare person in your particular State.

The real dilemma with folks like you is that you likely did not contribute to Social Security and rather will get a pension. You also have the right to speak with a counselor or a Human Resources person with whom you can question about how most govt-veterans go about using Medicare throughout your lifetime.

I've had the same Part D plan for years, but this year my insulin shot up in price. Did the Inflation Reduction Act not fix this yet?

Answer: Someone has not brought you up to speed. You always have choices. First of all, please do not forget to read your "ANOC" or Annual Notice of Change which is mailed to you every October which compares the current year costs to the following one. My guess is that you are paying much more premium per month since you don't have the means of checking other plans in your particular State. What is elusive is that a Part D plan can delete a drug that you take and you'd not know that this has occurred. Therefore, it is ESSENTIAL for you to call your company's customer service department, asking for a supervisor and determine which of your drugs are not a part of their drug formulary for the next year.

Insulin Price Cap: If you use insulin, Medicare capped monthly insulin costs at $35.00 apiece which began in 2023. Don't let a drug store clerk tell you that it is not $35.00 since they know nothing about Medicare and the Inflation Reduction Act. Furthermore, No-Cost Adult Vaccines: since 2023, vaccines under Medicare Part D are available at no cost to adults which can keep you protected without unexpected expenses. However, we cannot predict if insulin may be on the rise in the future due to our global economy.

However, NEVER simply retain the original Part D plan that you started with, since the volatility of pharmaceuticals is rampant at this time. Always use Medicare.gov and investigate if from one year to the next, not just insulin but all of your Rx's may have changed "TIERS". There are five drug tiers: Tier 1 is Preferred Generic, Tier 2 is Non-Preferred Generic, Tier 3 is Preferred Brand Name, Tier 4 is Non-Preferred Brand Name, and Tier 5 is a Specialty drug which is very expensive. The lower the tier, the cheaper the copay. Plus, be sure to use your plan's "Preferred" pharmacy & not the closest one to your home or the one with a drive-in window. That could cost you a lot of $$ over a 1 year time!!

I got a call from a "Medicare agent" promising me free groceries and I almost fell for it. Why is this kind of marketing allowed?

Answer: .Believe it or not, there ARE some plans that offer you free groceries and free over-the-counter products if you join their plan. This is an enticing offer and sometimes that very benefit overwhelms someone since anything free is a boon (supposedly) to your finances. You must look at the overall benefits of the plan & not just a "niche" benefits. The crackdown on enticements like that have already taken place a few years ago when Joe Namath, Jimmie Walker and actor William Devane talked about a plan that many people already had in place but didn't know it. The Centers for Medicare & Medicaid Services (CMS) forced this company to re-shoot those TV commercials to eliminate the misleading parts of their plan.

How do you approach educating clients who are new to Medicare versus those who are considering switching plans?

Answer: That's an easy one: Those veterans of the Medicare wars had better been explained at age 65 all of the ins & outs of Medicare since it is so very quirky. If I question these veterans and they simply don't recall having been taught what I consider to be "properly", I will treat those seniors just as I would with those first entering Medicare. As a longtime agent, I tell folks that there simply is no "cookie-cutter" means of teaching & advising Medicare. "Simply the rules, madam, simply the rules".

I teach Medicare at the local university every year for the past decade right before the Annual Open Enrollment period which should be close enough for everybody to "get the gist" of the 80% - 20% rule. That is: if you're having a procedure in a hospital (In-patient) that comes under the heading of Medicare's Part A (no cost/month usually), then Part A pays the 80% and your secondary pays most or all of the remaining 20%. BUT, if you're receiving treatment in a doctor's free-standing surgical center (Out-patient), the 80% is paid for by Medicare's Part B (has a monthly premium) with the remainder coming from your secondary insurance.

Constantly, I remind folks that there are basically THREE aspects of Medicare that you'll be paying for: A) your monthly Part B "Premium Payment" which is predicated on your 2-year old tax return on the line that is called your "Adjusted Gross Income". There is an "IRMAA" Income chart on Medicare.gov showing the most common (= the least amount in 2025 at $185.00 per month). This can be withdrawn from your Social Security Direct Deposit if you've begun to collect your SS entitlement., B) there is a one-time per year Part B "Deductible" which is $257.00 in 2025, and C) whether you've chosen a Medicare Supplement (which has a monthly premium) or a Medicare Advantage plan (the latter of which is free since it is government-subsidized). Then, depending upon which of the many plans are chosen, that will dictate your entire monthly money outlay.

I'm confused about the different tiers in Medicare Part D plans. How do they affect what I pay for my medications?

Answer: Most Part D plans exhibit 5 tiers of drugs: 1) Preferred Generic, 2) Non-Preferred Generic, 3) Preferred Brand Name, 4) Non-Preferred Brand Name, and 5) Specialty Drugs. The lowest the tier, the cheaper the copay.

Tiers are determined by Medicare (CMS) and are based upon the costs of bringing the drug to market (research & development, plus the ingredients). There are some categories of drugs that don't fit into that rule like Insulin ($35.00 apiece) and the ever-escalating costs of various inhalers.

My tip on paying the least amount of money is to always check with the online discount websites like GoodRx.com, costplusdrugs.com, simplecare.com, etc. There are also a number of Canadian online discount pharmacies that are available in order to check their cost to you. Please remember that should you decide to use a Canadian pharmacy, the drug cost will NOT be applied toward the 2025 annual drug deductible (max: $2,000.00).

Be advised that in 2025, you have 2 options: A) Using your Part D(rug) plan or in checking the drug formulary within your Advantage plan, vs. B) using an online pharmacy which you've investigated and contains a less expensive amount by printing a coupon from your PC. BUT, you cannot use both for the same drug. You CAN use either A or B for the various drugs you take, some of which might point you to your favorite local drug store, while others might dictate that you drive further away from your home to a "different" pharmacy which has better pricing for your drug. The only inconvenience is that you must check that your doctor knows which pharmacy to fax to with each individual drug/Rx.

What is the main benefit of Medicare Part D?

Answer: Whether you've ever been prescribed drugs or not, once you become Medicare-eligible, usually at age 65, if you either have NOT picked up an Advantage plan WITH drugs or a "Stand-Alone" Part D(rug) plan, you will have a Lifetime penalty imposed depending upon how many months you failed to enroll with any drug plan.

This penalty will be added on top of your monthly Part D plan. So, though your answer is obvious, I have had many clients who claim to be healthy and lucky enough not to need any prescriptions. Once they tell me that, I do mention everything that I've stated above and they will usually abide by my recommendation as there currently are drug plans with a zero monthly premium. Bear in mind also that you may be as healthy as a horse but once you're in a car accident, you're no longer healthy and will require some meds as part of your recovery process, even if they're just painkillers.

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

Answer: IRMAA (or Income-Related-Monthly-Adjustment-Amount) which is based upon your 2-year old tax return under the category of "Adjusted Gross Income" or AGI. There is a chart on the Medicare.gov website which you can find by putting those 5 letters into the search box and print out the chart. The least amount for 2025 is $185.00/month (predicated on a joint return of $206K or less). Then, regarding the higher AGI's, it can reach a maximum of $594.00 per month (is an AGI of over a half million $$ or greater when filing as an individual or $750K when filing jointly with your partner).

I would recommend that you "remind" Medicare of your lower income since at times, they will not necessarily "catch up" as quickly as you'd like them to (call 1-800-MEDICARE). Remember that chart contains SIX categories of AGI's so if you have a new lower income, it may not make any difference. You don't need to specifically report that since both the Medicare and the IRS computers usually communicate this info directly within 3 months (hopefully) after filing.

I need a hearing aid but I've heard Medicare doesn't cover them. Is there any way around this?

Answer: The fact that you included the above word "heard" is kind of ironic. You've heard wrong! Thus, I'd agree that you actually DO need a hearing aid. In fact, two of them! LOL. Medicare doesn't pay for the entire amount. But it will give you an allowance (this depends of which insurance company you've chosen when you turned age 65) toward the purchase of hearing aids. Some will permit that every year or two though there shouldn't be the need that quickly if they're fitted properly. Go to Costco (one of the least expensive places to buy a pair) and the cost (in AZ) is around $1, 699.00 and it can work with your iPhone.

Isn't it suspicious that Medicare Advantage plans offer gift cards and incentives to enroll?

Answer: There are rules in this area which are found on Medicare.gov. For example, if you attend an educational event, whomever is the host cannot specify names of ANY insurance companies that she/he is appointed with. AND by the same token, a gift card cannot be handed out as THAT IS ILLEGAL since that is considered to be "cash"! BUT, she/he can have light snacks available at a single event as long as it does not cost more than $15.00 per attendee. Anything valued more than that can cause a fine to be levied and a refresher course to be given to the agent.

My husband passed away and now my Medicare premiums went up. Why does losing someone raise your costs?

Answer: This can be complicated. It has to do with you & your husband's "Adjusted Gross Income" or "AGI" which is taken from your 2-yr. old tax return. If you've earned more than your husband during your respective careers, once he is out of the picture, Medicare only looks at your new and "individual" tax return. The least amount in 2025 for the Part B premium is $185.00 (as an individual filer, that means the "AGI" is $103,000.00 or less; but it can be as much as $594.00 per month if your AGI is $500K or greater). My best advice for you would be to make an appointment with a counselor at your nearest Social Security office to verify that the above example happened to be your case, or not.

What is Guaranteed Issue for Medicare Supplement plans, and when does it apply?

Answer: You are always a "GI" or a guaranteed issue person when you first become eligible for Medicare, usually at age 65 (you have a 7-month window to apply; 3 months before your birthday month; your actual birthday month and then 3 months after your birthday month for a grand total of 7 months). If an entire year elapses and you're now 66 years old, if you wanted to possibly change your 1st plan to another company's Supplement, you would have to go thru Underwriting to verify that you have NO pre-existing health conditions.

Steven Bleicher, Medicare Insurance Broker

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