Steven Litzsinger, Medicare Insurance Broker

Answer: There are circumstances where a Medicare Advantage plan can you drop you as a member, but it is regulated and can't be due to your health or increased utilization. Typically it is due to non-payment of premium, moving outside of covered service area, you become no longer eligible and enrolled in Part A and Part B as required, or the plan exits the market that you are living in, or the plan no longer meets the requirements to offer the plan through Medicare.

If you are dropped it will trigger a Special Enrollment Period (SEP) and you will be able to enroll in a new plan without waiting for Annual Enrollment Period (AEP) or Open Enrollment Period (OEP).

Answer: You have a several options to learn if a specific procedure is covered by original Medicare and if there will be any co pays , coinsurance, and /or deductible requirements triggered with having the procedure done.

1- Contact your Local, Licensed, Medicare Agent- They can quickly answer your question.

2- Visit www.Medicare.gov and look up covered procedures.

3- If you downloaded the Medicare App, What's Covered, you can look up the procedure on the app.

4- Call Medicare Directly at 800-Medicare

5- Ask the Provider's Office/Ordering Provider if the procedure will be covered

* Some procedures may be covered as part of the preventative/screening benefits as part of your Medicare benefits. Things like a mammogram, colonoscopy, etc...There are limitations and frequency requirements with included preventative and screening benefits.

* * Keep in mind, depending on where you have the procedure (inpatient / at the hospital) vs outpatient (freestanding Ambulatory Care Center/ Surgery Center) may have different cost shares. Also, there are typically costs associated with the procedure/services, and then there are professional fees (provider fees).

Answer: Like most things, there are various opinions on which option is best. Just because a Medicare Advantage plan works for you, it doesn't mean that it is the right plan for me, my needs, my budget, and my goals. If your Medicare Advantage is working for you and meeting your needs, that is great news. I will keep the information you shared in mind in the future if I elect to explore other options outside of my Medigap policy.

Answer: Drug Tiers is another way to easily identify categories of drugs (generic, preferred generic, Brand, Preferred Brand, Specialty/Non- Formulary Medications) and the associated cost shares by tier. Tier 1 is the lowest cost and Tier 5/6 is the highest cost share or coinsurance amount.

Example:

Tier 1-Preferred Generic/Generic (typically no cost or low cost share)

Tier 2-Preferred Brand

Tier 3- Brand (Mid range on cost- will see co pays/ coinsurance of $20+)

Tier 4- Specialty (higher cost and often involves % of coinsurance depending on the cost of the medication)

Tier 5/6- Non Formulary (highest cost share/may not be covered)

Please keep in mind, you can't assume a medication will be the same tier across all carriers and all plans. It is extremely important to verify your medications through all plans that you are considering to identify the best coverage and the least amount of out of pocket costs.

Out of Pocket Costs include: Deductibles, Co Pays, and Coinsurance

Answer: At this point, I'm sure you have heard about rising cost of premiums across Medicare Supplements. I wouldn't say that there are certain companies to avoid; however, I think there are certain carriers that are more favorable in certain markets. You can start by looking at what's available in your market.

If you want to learn more about certain carriers, historical performance, and want help identifying the best solution and carrier for your market, a licensed Medicare Agent will be a great resource for you and will help avoid some of the pitfalls.

For our clients, we complete a comprehensive review and access market analytics on the carrier, plans, and historical performance and share that information with clients as a means to educate, empower, and inspire clients to make informed decisions. The end goal is to enroll in a plan with carrier that is stable and has more predictable performance to avoid the drastic rate swings each year. The coverage is regulated at the federal level and the coverage is the same for ALL carriers, regardless of the logo.

You can also find great information on Medicare.gov and the FREE GUIDE, Choosing a Medigap policy. It has a lot of great information and key concepts to consider when you are selecting a plan and carrier.

Answer: Yes, there may be assistance (savings) if you have Medicare Part D Prescription Drug Coverage and can not afford the medication. When it is a brand drug that is typically more expensive, most manufacturer have discount codes, coupons, or savings program. You can easily identify the requirements and eligibility by visiting the manufacturer website or calling them directly. IN this case, Breztri is manufactured by AstraZeneca.

Answer: Hi there, Nurse Steve here answering your Medicare questions. So your question is related to being a snowbird and being able to have a plan that travels with you. The good news is all three of your options as a Medicare beneficiary have coverage. It's all about having the right plan.

So if you're on original Medicare and just have the red, white, and blue card, as long as they participate in a Medicare program or federal programs, they're going to accept that card regardless of what state you're in. If you're a beneficiary that has selected to go with a Medicare Advantage plan, the good news is they've really evolved over time.

Today, as long as you go with the Medicare Advantage plan that has a national network, they will actually travel with you as well. Now, the Medicare supplement has historically always been a great option for someone that's going to be split in their time between two homes or someone that likes to travel and really wants to avoid any network nuances that are out there.

So again, all three options: original Medicare, a Medicare Advantage plan, as long as it has a national network that you can tap into, or has clauses around reciprocity if you were traveling.

Answer: Hi there, Nurse Steve here with another answer to a Medicare question. So the question that was presented was, "My friend said she got a free annual physical with Medicare, but my doctor billed me. What's going on?"

Well, what you get with Medicare is an annual wellness visit. So if you're getting a physical or they're treating an illness, that's going to be billed separately. What you get with your Medicare benefits is a free annual wellness visit. Wellness is the key component of their wellness visit. So if it is a physical, that is something that there is a fee or a copay associated with seeing a physician for a physical exam.

I hope that answers your question. Have a great day!

Answer: Medicare 101 should be educational and are designed to help people plan and prepare for enrolling into their Medicare benefits, along with enrollment timelines/periods, penalties for delayed or non-enrollment during the specified windows, things to consider if you plan to work past 65 and delay enrollment into Part B/Part D.

I'm sorry to hear you had a bad experience. I encourage you to try another one with a different teacher/agent, or consider a virtual Medicare 101 seminar. We offer Medicare 101 every week and throughout the entire year to help as many people as possible.

The presentation is carrier agnostic, unbiased, and outlines the fundamentals of Original Medicare, Enrollment Periods, Penalties, and options for beneficiaries; such as, Original Medicare Vs Medicare Advantage Vs Medicare Supplement (MediGap).

It is our goal to help educate, empower, and prepare our attendees to make informed decisions about their Medicare options based on their individual needs, budgets, and goals of care. Yes, you had a bad experience and that is not typical. You can get great information to assist and complement the resources provided by Medicare.gov

Answer: Here are 3 things you can do to better support your parents, friends, and family when it comes to navigating all things Medicare.

1. Start with Active Listening and Being Present for them along their Medicare journey.

*As a Medicare Agent, I always recommend inviting friends/family that they trust to be part of the process and as an ongoing support throughout their Medicare journey. Your parents will feel more comfortable when there is someone there they already know and trust and is already familiar with their unique situation and potential needs.

2. Do Not Make Assumptions

- It's important to understand that each person is different and how they feel about navigating Medicare, what information they already know about Medicare, and if there are or are not any questions, concerns, or gaps in their Medicare Discovery and Enrollment journey.

3. Participate in as many of the meetings about Medicare with them.

-You will also someday be at this important milestone (Medicare and Retirement) and can get a head start on building a solid foundation about the process and options available through your Medicare benefits.

- I always encourage clients and their support team to take notes, ask questions, and fully engage in the process. It's a lot of information, especially for someone new to Medicare, and there can be a fear of missing something or not fully understanding or forgetting to ask about important details.

- It's ok to ask someone to repeat or restate any portion of the discussion.

- Before the conclusion of a meeting, ask the Agent/Facilitator to recap key details and ask if there are any lingering questions or elements that need to be re-visited before moving forward with making such an important decision.

As a support for your parents, it's about being present, available, and resource to help them navigate their journey. You will be a great resource for them. I promise!

Answer: Original Medicare does not include "dental benefits"; but, there are situations that Medicare may cover some or all of the costs for dental implants. If it is an isolated dental issue, it most likely will not be covered by Medicare.

However, there are Medicare Advantage and stand-alone Dental/Vision/Hearing Plans that have dental benefits and they may or may not cover dental implants. If you are anticipating needing a dental implant, its important that you complete your due diligence and review all inclusion and exclusion clauses on the plan that you are considering to ensure it will meet your needs and cover your desired benefits.

Reading the fine print can be overwhelming. We recommend connecting with a local, trusted, agent to help you navigate your needs and explore the plans that will provide the best coverage for your unique needs.

Answer: There are specific situations post surgery that may qualify for Medicare to cover a home health aide. Typically, it is in combination with skilled services post op and in the home.

Prior to surgery it is important to discuss the entire surgical journey with the care team. That includes pre-op, operative/surgery expectations, and post op care. Depending on the type of coverage you have, will dictate what type of care is available as part of your benefits.

If you are still unsure and have questions, reach out to a local, trusted, Medicare agent. A licensed Medicare Agent can speak in more detail about coverage benefits and resources available to help you navigate your healthcare journey.

You can also visit Medicare.gov website for the most up to date information and resources related to your Medicare benefits.

Answer: Original Medicare covers limited cost associated for chiropractic care. It primarily covers manual manipulation.

However, Medicare Advantage plans often cover chiropractic care for a low co pay/cost share amount. You will need to verify the benefit/coverage for your specific plan.

Answer: 5 Steps Every Client Can Follow To Ensure They Stay Informed, Educated, And Prepared for All Things Related to Medicare Plans, Options, and Policies:

1- Subscribe to the CMS/Medicare.gov email and notification List;

2- Review Your Annual Notice Of Change that comes out each year in October from your current plan carrier;

3- Review the Annual Medicare and You handbook issued by Medicare for reference throughout the year;

4- Schedule a Meeting with a Local, Trusted, Medicare Agent and Advisor to review your current plan and partner to develop a plan to meet your needs for the upcoming year;

5- Attend Local, Medicare 101 and Medicare Updates, Events that are hosted by licensed, trained, subject matter experts to get the most up to date information each year and strategies to maximize your benefits and options for the upcoming year.

Answer: Once you have been in the US for 5 continuous years and meet the federal requirements, you can enroll in Medicare. If you haven't worked in the US and earned the credits necessary, you may have to pay a premium to access Part A and Part B benefits through Social Security. It is best to plan ahead and reach out to the a local, trusted broker that can help you navigate the requirements, gather the necessary documentation, and be prepared for exploring all of your options once you have been in the US for 5 continuous years.

There are other, very specific situations, that non US citizens may be eligible for state and federal benefits. A full list of eligible people/situations can be found on Medicare.gov.

Or, you can speak with a licensed Medicare Agent that can help you navigate the state and federal programs that are available to you.

Answer: As a Medicare Beneficiary, you have the option to add travel coverage, as well as, other supplemental plans to your main medical coverage.

However, before you pay for an additional policy/coverage; I highly recommend assessing your current coverage. If you have Original Medicare ( Red, White, Blue Card), Medicare Supplement, and some of the Medicare Advantage Plans. You may already be covered for travel within the US. It will depend on your current plan and the benefits associated with the plan.

We have clients that travel often and elect to add a travel insurance policy to ensure FULL PROTECTION when traveling (domestic and international) as a means to avoid any uncovered, out of network expenses associated with the unplanned medical events while traveling to have peace of mind.

First, assess if your current coverage provides the desired protection. If not, then consider if this is coverage for a single trip, extended period of time (1-3 months as a snowbird), or continuous for multiple trips, both domestic and international.

We also encourage our clients to review their other insurance policy (auto, home, life, etc..) and see if any of their credit cards have travel insurance included on them.

You don't need insurance, until you NEED INSURANCE!~ It's always best to be prepared and PROTECTED!

Answer: You can certainly meet with any broker you elect to partner with and trust. The key is to find a local, trusted, broker that is accessible, helpful, and can help you navigate your benefits and options with ease and confidence.

It isn't recommended to work with multiple brokers and enroll in multiple plans. However, If you aren't sure of the fit with a broker or not sure you are getting the help you need, simply say thank you and let them know you will reach out with any additional questions or needs. Just because you meet with a broker, it doesn't mean they automatically earn your trust or business. It has to be a good fit for both parties.

Also, if you are currently working with a broker and they are no longer providing support and bringing any value, it is ok to find a new broker. A broker should add value and be a subject matter expert that partners with you and your family to help you navigate all things related to Medicare.

Just because a broker assisted with your enrollment previously doesn't mean you are married to the broker indefinitely. The partnership should be ongoing and provide value to you and provide you with ongoing assistance as needed and requested as a beneficiary.

You have options!

Answer: Yes, an Medicare Agents can work with people with Dementia.

If the person can no longer make decisions for themselves due to disease progression and inability to make sound decisions on their own behalf, the agent can work with the spouse/POA/Guardian, to identify the best plan and coverage for the individual.

There are state and federal laws that protect beneficiaries and their rights in the event they can no longer make their own decisions. If there isn't a family member or designated person to act as the POA/guardian, the court can appoint a guardian to protect the beneficiary. If there is a court appointed guardian, the licensed Medicare agent will work directly with them to assess all available plans and options and determine the best Medicare program for the beneficiary.

Answer: It may or may not cover everything on your current employer's plan, but you can rest assured that Medicare offers comprehensive coverage (Part A- Hospital, Part B- Outpatient, and Part D- Prescription Drug Plan). While there may be some similarities between Medicare and Employer Sponsored Health Insurance Plans, it's a separate program with different rules.

Both programs are regulated by state and federal laws as it relates to plan design, benefits, and protection.

In fact, most of our clients have reported that the Medicare benefits have been better than their employer offered plans and often is a lower out of pocket cost for better coverage.

If you would like to learn more about Medicare or get help comparing the risks/out of pocket cost for healthcare between an employer plan and Medicare; a local, trusted, Medicare agent can help you compare and contrast the two programs and provide you with the information you need to make an informed decision.

Answer: Medicare's "Extra Help" program, also known as the Part D Low-Income Subsidy, provides financial assistance for Medicare prescription drug costs (Part D) to people with limited income and resources. It helps pay for monthly premiums, annual deductibles, and copayments, with costs in 2025 capped at $0 premium, $0 deductible, and copayments of up to $4.90 for generic drugs and $12.15 for brand-name drugs.

If you haven't checked to see if you qualify for the extra help, look into it!

In fact, we assess and evaluate this option with each of our clients as part of the routine new client intake and ongoing annually during the annual review.

If you need help or want more information you can reach out to a local, trusted, Medicare agent, local SHIP office, contact Medicare.gov, and discuss with your current insurance carriers.

Answer: This is a very common question. Original Medicare does not offer fitness/gym benefits. If a beneficiary elects to add a Medicare Supplement Plan (MediGap Policy) or Enroll in a Medicare Advantage Plan, they may get "EXTRA BENEFITS" such as a gym membership/access through program like: SilverSneakers (Aetna, Humana, Anthem, etc..), SilverFit (Healthspring), RenewActive (UHC), etc.... Often the extra benefits like SilverSNeakers is at no additional cost to the beneficiaries.

Though there are many Medicare Advantage plans with the extra benefits, some may not offer the extra benefit. It's important to assess if the plans you are considering include the extra benefit (SilverSneakers) and if you local gyms are included in the program.

In addition to gym/fitness benefits, some plans include extra wellness programs and resources even at home. These are great benefits to promote better health and wellness.

Answer: Yes, Medicare covers home health services if you are homebound, need skilled care on a part-time or intermittent basis, and are under the care of a doctor.

Covered services include skilled nursing care, physical and occupational therapy, speech-language pathology, and medical social services.

Medicare typically pays 100% of the approved costs for these services.

Eligibility Requirements:

Homebound: You have difficulty leaving your home without help, and it is a major effort to do so.

Skilled care: You need part-time or intermittent skilled nursing care or therapy services.

Doctor's order: A doctor or other qualified healthcare provider must certify that you need home health services and order your care.

Medicare-certified agency: Services must be provided by a Medicare-certified home health agency.

Services that may be covered:

Skilled nursing care: Wound care, injections, and education on managing a condition.

Therapy: Physical, occupational, and speech-language therapy.

Medical social services: Help with social and emotional issues related to your illness.

Home health aide: Medicare will pay for an aide if you also need skilled care, but not if you only need personal care.

What is generally not covered:

24-hour care: Medicare does not cover around-the-clock care at home.

Homemaker services: Shopping, cleaning, and meal delivery are typically not covered.

Custodial care: Help with daily activities like bathing, dressing, and eating is generally not covered, though it may be included as part of a care plan that also includes skilled care.

Answer: Yes, there are programs specifically for beneficiaries that may need some "extra help". There are both state and federal programs that can provide additional assistance with covering the cost of medications.

Also, as of 2025, Medicare now offers a Medicare Prescription Payment Plan (MPPP) that will help balance your cost with equal payments over the 12 months. A great solution for people that are facing higher cost in months 1-3 of the year and then hitting their max out of pocket (catastrophic phase).

Since the cost shares (co pays, coinsurance, deductibles), premiums, and formularies change each year and can vary among plans and carriers, it is important to run your medications through each of the available plans within your market to ensure you are on the best and most cost effective Medicare Advantage Prescription Drug or Part D- Stand alone Drug Plan for the upcoming year.

In fact, when you work with a licensed Medicare Agent, they can provide you with your annual cost of medications and provide an outline of the you monthly cost, starting with the first fill staring January.

Answer: Medicare Supplement Plan G offers more comprehensive coverage with higher monthly premiums and lower, more predictable out-of-pocket costs, while Plan K offers lower monthly premiums but requires cost-sharing until an annual out-of-pocket limit is met.

Plan K has an annual out of pocket limit that applies and Plan G does not.

Both Plan K and Plan G are good options. It depends on your budget and individual needs to determine which plan may be best for you. This is where a licensed Medicare Agent can help you assess the pros and cons of each available option and make sure you understand the cost share and risks associate with each option.

Answer: You have a few options to verify that a plan will cover the Brand Medication and to get the cost share (copay or coinsurance) associated with the medication.

1- (quickest and easiest) Contact a local and trusted Medicare Agent. They can quickly look up the medication across all available Part D plans in your area and provide the information to you.

2- Look it up on Medicare.gov

3- Contact Medicare at the number listed below.

Need help beyond what’s on Medicare.gov?

You can talk or live chat with a real person, 24 hours a day, 7 days a week (except some federal holidays.)

1-800-MEDICARE (1-800-633-4227)

Answer: Medicare covers more telehealth services if you live in a rural area and you go to an office or medical facility that’s also in a rural area (in the U.S.) for your telehealth visit. Some of the telehealth reimbursement for providers that originated from the special provisions due to Covid has since expired as of October 2025. Therefore, it's important to assess your coverage and needs with your local primary care provider and identify the best plan that can meet your needs.

You may also consider a Medicare Advantage Plan (Part C) that often has more telehealth coverage than original Medicare.

Answer: You have options and just a plan/option works for one person doesn't automatically mean it will work the same for the next person.

Your plan selection and due diligences should be focused on you as a individual with your own unique needs.

You can consult a local, trusted, licensed Medicare Agent that can assist you will evaluating all of your options, risks, and out of pocket costs each year and it's FREE! There is no costs to you as a Medicare Beneficiary.

Answer: Medicare Advantage is Medicare and simply means that a non-government 3rd party (carrier) is administering the Medicare benefits.

There are pros and cons to each option.

Original "Traditional" Medicare- Wide Network, No Max Out of Pocket Limits to Cost Shares

Medicare Advantage- Narrow Network that is Specific to Carrier, reduces risks with Max Out of Pocket (MOOP) per year, and extra benefits that are not part of Original Medicare like Dental, Vision, Hearing, Transportation, OTC, etc....

We serve clients that have Original Medicare with a Stand-alone Part D, Original Medicare with a Stand alone Part D and Medicare Supplement Plan, and clients that have elected to take advantage of the reduced MOOP risks and extra benefits associated with selecting a Medicare Advantage Plan.

Regardless of the 3 aforementioned options, they are ALL MEDICARE and operate and abide by the same rules and coverage determination.

Answer: Unfortunately, you can conflicting information about network providers. We always recommend verifying that your provider(s) are in network through one of the following pathways:

- Contact a local, Trusted, Medicare Agent;

- Verify through the carrier website;

- Contacting the member services of the selected plan prior to enrolling;

- Asks your provider if they plan to remain in network for the year or if they anticipate any changes on plans they will accept in the future;

- or contact support at Medicare.gov.

As an agent, I verify providers are in network through a minimum of 2 sources. If conflicting information is discovered (and it happens...a lot this year), we take additional steps to verify and confirm in network prior to advising a client to enroll and risks losing their trusted providers.

Answer: I think it is assuming that the most expensive, stand-alone part D (prescription drug plan) is the only plan to cover their medications. Often we find that the zero dollar premium and low cost part D plans cover most drugs.

Before you overpay for a Part D plan, consider verifying your medications are on the plan's formulary for the year and compare the cost for the medications. When carriers have more than one Part D plan available, they can also have different cost share (co pays, coinsurance, and deductible requirements) and categorized in different tier levels that will impact your out of pocket cost for your medications.

If you need help, reach out to a local, trusted, Medicare advisor, SHIP, or visit the Medicare.gov website for more information, best practices, and resources to help you assess and compare your options for the upcoming year.

Answer: Yes, the 2025 Part D changes will help with expensive specialty medications, primarily due to the new $2,000 out-of-pocket (OOP) cap and the option to use a Medicare Prescription Payment Plan. The OOP cap means you won't have to pay more after your total yearly drug costs reach $2,000, and the payment plan allows you to spread your costs out over 12 months instead of paying large amounts at the pharmacy.

In 2026, the Max Out of Pocket (MOOP) for covered medications will be $2,100.

It's important to check the cost of your specific medications each year. I highly recommend working with a local, trusted, Medicare agent that can assist with review and can provide you with the estimated cost of your medications for the year and what to expect for out of pocket costs starting with your first fill in January.

You can also visit the Medicare.gov website and enter you medications. However, there have been some inaccuracies with the website this year and may require entering the medication on the site and then cross walking them with the 2026 formulary for your plan.

Answer: It is not required to seek help and support in navigating your Medicare options, but it is highly recommended due to the growing complexities with Medicare. There have been some big changes in Medicare over the last 5 years and working with a local, trusted, advisor can help make it easy and simple to navigate the best plans and options for you as an individual.

Agents are educated and trained on the most up to date information related to Medicare and will take the large amount of information related to Medicare and summarize it for you and help educate you on how it applies to you and your needs.

Why not take advantage of a zero dollar cost for expert guidance, support, and resources?

Real People. Real Advisors. Real Solutions.

Answer: If you move to a rural area, there may be less options available for MAPD plans. However, there are many counties and states that have at least one MAPD plan available. It's important to assess the area that you are planning to move to get a better understanding of available plans available in that specific area of the state.

In addition, it is wise to research and assess healthcare access before moving to a new area. If Medicare Advantage (MAPD) plans are not available in the rural area, Traditional Medicare and Medicare Supplement Plans are great options that ensure open access to providers across the country without any network limitations.

If a provider participates with state and federal programs (Medicaid and Medicare), you will have access to them through your Medicare coverage from both Traditional and Medicare Supplement plans.

Answer: Typically, there are limits and/or a Max Out Of Pocket (MOOP) for each of the 3 Medicare options and the MOOP varies by option (Traditional Medicare, Medicare Supplement, and

Medicare Advantage , carrier (UHC, Aetna, Humana, Cigna, Devoted, Anthem, etc.....), and by plan (HMO, PPO, CSNP, DSNP, ETC..).

3 Medicare Options:

1- Traditional Medicare does NOT have a Max Out of Pocket (MOOP);

2- Medicare Supplement MOOP varies by plan (A, B, C, D, F, G, K, L, M, etc...) and is typically cheaper and less risks than traditional Medicare;

3-Medicare Advantage has a MOOP and start as low as $2, 300.00 in Missouri for 2026.

Medicare Advantage MOOP (Maximum Out-of-Pocket) is the annual cap on the amount you pay for covered Part A and Part B services in a Medicare Advantage plan. Once you reach this limit, the plan pays 100% of your costs for the rest of the year. This protects you from unlimited costs, as Original Medicare does not have a MOOP limit.

What is MOOP?

Annual cap: MOOP is the most you'll pay out-of-pocket for services covered by your plan in a calendar year and includes the following costs: deductibles, copayments, and coinsurance for Part A and Part B services. The MOOP Is reset each year and the Maximum allowed MOOP set by Medicare for 2026 is $9, 350.00 per year. Though most Medicare Advantage Plans have a much lower MOOP.

Answer: If you are currently on a Medicare Advantage Plan, you can switch Medicare Advantage Plans during the periods:

1- Annual Enrollment Period (AEP) that is from Oct 15 - Dec 7th each year;

2-Mediare Advantage Open Enrollment Period (OEP) that runs from Jan. 1- March 31st each year;

3- Special Enrollment Period (SEP)

If you have questions about special conditions, situations, and circumstances that trigger a Special Enrollment Period (SEP) it is best to visit Medicare.gov or speak with a local, trusted, licensed, Medicare Agent that can help you navigate ALL of your Medicare options.

Answer: Yes, the shingles vaccine is covered by Medicare under Part D. In fact, it is covered and recommended as a preventive services for older adults.

Answer: In my experience, people that have been unhappy with Medicare Advantage (MA) plans are typically unhappy related to one of the following scenarios:

- Enrolled in Medicare Advantage (MA) Plan without understanding the pros and cons;

- Enrolled in a MA plan that was too restrictive/limited networks;

- Enrolled in a MA plan that didn't meet their basic needs and only promoted the "EXTRAS"

As of today, I have never had a client that enrolled in Medicare Advantage with the right information, education, and knowledge about how they work in comparison to Traditional Medicare, come back to disenroll or express dissatisfaction.

In fact, the majority of the complaints and concerns come from people that are not enrolled or have never been enrolled on a MA plan. Many of the people have been given wrong information, mislead, or lack firsthand experience around how MA works and how it compares to Traditional Medicare. MA plans aren't for everyone, but they are certainly a great option for many Medicare Beneficiaries.

A survey published by Better Medicare Alliance in 2023 reported a 95% satisfaction rate with MA overall. I don't think you will find that level of satisfaction with commercial/employer plans. I also believe that is why MA enrollment has continued to increase year over year and as of 2025, more than 50% of Medicare beneficiaries have elected to enroll in a MA plan.

Please note: there are pros and cons to each option (Traditional Medicare, Medicare Supplement, and Medicare Advantage).

As a consumer, you need to consider your individual needs, access, and benefits that are the most beneficial to you and your health and wellbeing. I think having a local, trusted, insurance broker and advisor, can help you navigate all of the available options and provide the necessary education as it relates to the pros/cons to each option.

Answer: No!

There are local and national coverage determination set by Medicare that serve as the guidelines that every provider and payer must follow. If there isn't a Medicare coverage determination, a Medicare Advantage Plan may have their own coverage determination based on evidence based care and established clinical guidelines.

If you have a question about a specific test you are considering, I always recommend checking in 1 of 2 spots.

1. Medicare Website (www.medicare.gov) and look up the test and cost information. This ensures that it will be covered and reduce your risks of paying for non-covered blood test.

2. If you have a Medicare Advantage plan, you can also review the blood test and coverage information through their website / member portal or simply reaching out to member services.

Most labs/hospital/clinics are aware of which blood test are covered by Medicare and if there are concerns, they will typically make you aware it is not covered, explain the potential cost of the blood test if it is not covered, and may have you sign a document explaining that you will be responsible for the cost of the uncovered test if the claim is denied. This will avoid a financial loss to the clinic/lab, and will avoid an unexpected out of pocket cost to you as a member.

If there are any questions or doubt, verify with the Medicare before proceeding with any potentially not covered blood test.

Answer: Traditional Medicare does not cover Dental and Vision. However, it is available for Medicare members through 2 options:

1. You can enroll in a Medicare Advantage plan that offers "Extra Benefits" such as Dental and Vision; or

2. You can purchase a stand alone Dental and Vision Plan (your Medicare Agent Can Assist You).

Alternatives to Traditional Coverage:

You can get access to Savings, Discounts, and Benefits through other various programs; such as, AARP, AAA, Health and Wellness Clubs, Professional Organizations/Associations, Membership Programs, and Direct to Consumer/Self Pay (DTC) programs.

* If you are eligible for Medicaid and Medicare, you may have access to benefits through the state Medicaid program that Medicare doesn't cover. Your licensed Medicare Agent can verify your eligibility and connect you to state (Medicaid) resources.

Answer: Yes.

If you lose health coverage through your employer and you are eligible for Medicare, it warrants a Special Enrollment Period(SEP) and you can elect to enroll in your Medicare benefits.

If you have questions regarding SEPs, you can contact your Licensed Medicare Agent for answers and support, or visit the Medicare website for answers related to Enrollment and Special Enrollment Periods.

Website:

www.medicare.gov

Answer: Options:

1. First- ask your Primary Care Provider if they were able to submit the prior authorization, supporting notes and documentation required for the request; if yes and still denied;

2. Consider asking the Primary Care Provider to do a Peer to Peer call with the plan Medical Director for further discussion and insight around the plan's decision;

3. Appeal the decision through the carrier specific appeal process and be prepared to present all supporting documentation and address the reason for the denial specifically as part of the strategy;

4. If still denied and deemed necessary by your primary care provider/treatment team; escalate the appeal through the carrier to the next level of review and appeal;

5. If no resolution and the treatment team deems the referral as absolutely necessary and there is peer reviewed, evidence based, clinical support and medical necessity, you can escalate the appeal to CMS through their appeal process.

Typically, the denial is related to lack of prior authorization being filed, lack of supporting documentation and/or clinical evidence of medical necessity, or failure to comply with step therapy and conservative treatment options first. In fact, most of the denials are overturned when they have the supporting information and there is medical necessity to support the request.

You can always reach out member service of the plan or contact your local, trusted, Licensed Medicare Agent for support and guidance around the how to appeal and navigate the process.

Answer: I love helping clients navigate their healthcare journey and optimize their health. I experience a great deal of satisfaction and joy helping friends, family, and clients navigate their Medicare journey and when I help them access resources and tools that have a positive impact on them.

There is nothing more rewarding than helping a client save money, gain access to providers, treatments, benefits, and resources that can help them live happier, healthier, lives.

Answer: We always recommend working with an agent, or trusted advisor, to assess the best plan for you individual needs and medications. We approach the process as team with our clients and help them identify the Total Cost of Medications for the year.

This includes the following:

Cost of Premiums + Prescription Drug Deductibles + Co Pays/Coinsurance = Total Cost of Medications

Each Prescription Drug Plan is different and so are the following variables:

- Formulary (Which Medications are Covered)

- Co Pays/ Coinsurance (how much the member is responsible to pay for each tier (generic, brand, specialty, and non-formulary)

- Pharmacy Partners (Preferred, In Network and Out of Network Cost Shares)

- Deductibles

Answer: You have a few options:

- Remain with the specialist and request an out of network exception through the carrier/plan when there is a medical necessity, lack of other specialist in the network within a reasonable distance, and for continuity of care;

- Remain with the specialist and assume out of network costs;

- Visit the member service website/portal to identify a specialist that is in network and accepting new patients (the website will have the most up to date information regarding in-network providers);

- Call your Trusted, Advisor and Medicare Agent for Support and Guidance;

- Contact member services for a recommendations of available in network specialist;

- or Notify your primary care provider and see who they recommend as part of their preferred referrals/specialist within the shared network of your plan.

The goal is minimize any disruption in care and treatment. Your agent and plan will help you navigate all available options and help you identify the best solution.

Answer: Great Question! If you parents are out of state and require Emergency Care, they will be able to access emergent care and it will be covered. If you are on a Medicare Advantage plan and it is out of network and deemed non-emergent, you could be responsible for higher cost share and may have less or no coverage for out of network care when it is deemed out of network and non-emergent.

If the care at the hospital is out of state and non-emergent, you will need to verify your coverage through your plan to see if your plan allows for out of state, non-emergent, care at the hospitals outside of your plan network. Each plan (PPO, HMO, POS, PFFS, etc..) typically has it's own network and coverage levels based on in and out of network. Always, Always, check with your plan or contact your agent to better understand your coverage options before traveling to an out of state hospital for non-emergent care.

We always recommend that our clients consider plans that will meet their needs and if they travel a lot, we recommend they consider an option that has more flexibility across regional and state networks as seen with plans that have a national footprint and national networks.

Today, this is can be achieved through all three Medicare options: Traditional Medicare, Medicare Supplement, and Medicare Advantage. The key is to be proactive and select a plan that can accommodate your individual travel needs and will ensure access to great care in the states that they plan to frequent. The goal is avoid paying higher cost shares for accessing out of network care when possible.

If you are on Traditional Medicare and/or have Medicare Supplement, you will have broader access and can typically be seen at any hospital that is participating with the Medicare program.

Answer: Medicare has gotten more complex over the years and many Medicare beneficiaries struggle with understanding, navigating, and accessing their benefits.

A licensed Medicare agent is a subject matter expert that remains up to date and current with all things related Medicare and can make navigating your benefits and all available options much easier and less frustrating for you and your family.

When you are overwhelmed by all of the choices and the noise around your benefit options (traditional Medicare, Medicare Supplement, Prescription Drug Plans, and Medicare Advantage) and the extra benefits on top of traditional Medicare, an agent can simplify it and highlight the key differences between each option, the pros and cons with each option, and help you as the beneficiary make an informed decision.

Please keep in mind, the Medicare Agent is your resource and advocate throughout the year and not just during Annual Enrollment Period (AEP). A local, trusted, advisor and licensed Medicare agent can help you maximize your benefits, reduce your risks, gain insight to the total cost of care and max out of pocket, and help you identify the best plan to meet your individual needs.

A good, value added, Medicare Agent will maintain communication and engagement throughout the year and will take a proactive approach to any upcoming or pending changes and help you navigate any concerns or issues along the way.

The goal is to make your Medicare journey easier and to optimize your health and wellness through the various Medicare programs, benefits, and resources.

As a registered nurse and licensed Medicare Agent, we leverage our industry knowledge, along with our clinical expertise, to ensure our clients have access to the best care and programs in the market.

Answer: Traditional Medicare Part A Coverage as it relates to hospital stays.

Below is the information provided by Medicare.gov. I will provide a direct link at the bottom of the post.

Part A costs: What you pay in 2025:

Premium

$0 for most people (because they or a spouse paid Medicare taxes long enough while working - generally at least 10 years). If you get Medicare earlier than age 65, you won’t pay a Part A premium. This is sometimes called “premium-free Part A.”

Do I qualify for premium-free Part A?

If you don’t qualify for premium-free Part A: You might be able to buy it. You’ll pay either $285 or $518 each month for Part A, depending on how long you or your spouse worked and paid Medicare taxes.

Remember:

You also have to sign up for Part B to buy Part A. Learn more about how Medicare works.

If you don’t buy Part A when you’re first eligible for Medicare (usually when you turn 65), you might pay a penalty. Find out more about how to avoid the Part A penalty.

Deductible

$1,676 for each inpatient hospital benefit period, before Original Medicare starts to pay.

There’s no limit to the number of benefit periods you can have in a year. This means you may pay the deductible more than once in a year. How do benefit periods work?

Inpatient stay

Days 1-60: $0 after you pay your Part A deductible.

Days 61-90: $419 each day.

Days 91-150: $838 each day while using your 60 lifetime reserve days.

After day 150: You pay all costs.

Link:

https://www.medicare.gov/basics/costs/medicare-costs