Tanja Roulhac, Medicare Insurance Broker

Answer: The agent is knowledgeable in the policies that govern Medicare, Social Security and Insurance. That expertise is needed to navigate the various products available to meet the needs of seniors.

Answer: Some Medicare Advantage plans have a $0 monthly premium, this does not mean they are entirely free. Beneficiaries still must pay their Medicare Part B premium (which is typically deducted from Social Security benefits) regardless of whether they choose a Medicare Advantage plan.

Answer: Physical therapy is covered under Medicare Part B, however you must first meet your deductible then benefits are paid. Medicare will pay 80% and the beneficiary is responsible for 20% of the approved cost.

Answer: Choosing between Original Medicare and a Medicare Advantage plan depends on your personal health needs, preferences, and circumstances.

Original Medicare (Part A and Part B)

Coverage: Hospital insurance (Part A) and medical insurance (Part B).

Flexibility: You can see any doctor or specialist that accepts Medicare without needing a referral.

Costs: You pay premiums for Part B, and typically deductibles and coinsurance for services.

Additional Coverage: You may need to buy a separate Part D plan for prescription drugs and/or a Medigap policy for extra coverage.

Medicare Advantage (Part C)

Coverage: Includes everything Original Medicare covers plus often additional benefits like vision, dental, hearing, and sometimes prescription drugs.

Network: Generally requires you to use a network of doctors and hospitals; may require referrals for specialists.

Costs: Often lower premiums than Original Medicare + Medigap, but you might have copayments or coinsurance with each service.

Extra perks: Some plans offer fitness programs, transportation, or wellness benefits.

Who to Listen To? You decide what is best for you. I am available to assist with Part D carriers or if you choose a Medicare Advantage, I will assist you with choosing the carrier that best meets your needs.

I hope this helps.

Tanja Roulhac,

Licensed Medicare Broker

Answer: 1. List Your Medications

Make a complete list of all your current medications, including:

Prescription drugs (name, dosage, frequency)

Over-the-counter medications you use regularly

2. Check Medicare Part D Formularies

Each Part D plan has a "formulary," which is the list of covered drugs. Check if all your medications are included in the formulary of the plan you are considering.

3. Consider Formulary Tiers

Medications in formularies are categorized in tiers that affect your cost-sharing:

Lower tiers usually mean lower copayments.

Specialty or brand-name drugs might be in higher tiers with higher costs. Try to find a plan where your medications fall into lower-cost tiers if possible.

4. Use the Plan Finder Tool

Use Medicare’s official Plan Finder tool (on Medicare.gov) to:

Enter your medications

See which plans cover them

Compare estimated yearly costs including premiums, deductibles, and copays

5. Watch for Coverage Rules

Some drugs may have:

Prior authorization requirements

Quantity limits

Step therapy (try a lower-cost drug first)

Check these details to avoid surprises.

6. Consider Pharmacy Networks

Some plans offer lower costs if you use preferred pharmacies or mail-order services. Check if your preferred pharmacy is in-network.

7. Review Annually

Formularies and costs change yearly. Review your plan during the Medicare Open Enrollment Period (Oct 15 - Dec 7) to ensure your medications remain covered at affordable costs.

Answer: What "Zero-Premium" Means

A zero-premium Medicare Advantage plan means you do not have to pay a monthly premium for the plan itself.

However, this does not mean you won’t have to pay any other costs.

What You Still May Have to Pay

Copayments or coinsurance for doctor visits, specialist visits, hospital stays, and other services.

Deductibles before coverage starts for some services or drugs.

Costs for services not covered by the plan.

Premium for Medicare Part B, which you must keep paying even if your Medicare Advantage plan has no premium.

Important to Remember

Think of zero-premium as just one piece of the total cost puzzle. While it can help reduce your monthly out-of-pocket spending, you’ll likely still pay when using healthcare services.

Answer: The aging population is projected to significantly strain Medicare Part A (Hospital Insurance) funds due to increased enrollment and rising healthcare costs.

The Hospital Insurance Trust Fund is expected to be depleted by 2036, at which point it could only cover about 89% of scheduled benefits without reforms.

This impact stems from a growing number of beneficiaries (e.g., baby boomers aging into Medicare) and higher per-capita spending on hospital services, with overall Medicare expenditures growing faster than the economy.

Answer: Medicare Advantage (MA) plans do not consistently save money for the Medicare program overall. In fact, CMS reports and studies (e.g., from KFF and MedPAC) indicate that MA plans often result in higher spending per enrollee compared to traditional Medicare, due to overpayments, administrative costs, and increased utilization. For instance, a 2021 KFF analysis estimated that MA added $7 billion in excess costs in 2019 alone.

While some MA plans may offer lower premiums or out-of-pocket savings for individual beneficiaries, the program as a whole has not generated net savings and contributes to Medicare's financial challenges.

Answer: Yes, generally, you may have to answer health questions when switching from one Medigap plan to another, but it depends on your situation. Here's a quick breakdown based on Medicare rules:

Outside Your Initial Enrollment Period: If you're not in your 6-month initial enrollment window (starting when you turn 65 and have Part B), insurers can require medical underwriting. This means you'll likely need to answer health questions, and they could deny coverage or increase premiums based on your health.

Guaranteed Issue Rights: You won't have to answer health questions if you're switching during a guaranteed issue period, such as:

Within 6 months of enrolling in Part B at age 65+.

If you lose other coverage (e.g., employer plan) and meet specific criteria.

In certain situations, like moving to a new state or your plan being discontinued.

Key Advice: Always check with the specific insurance company or use the official Medicare website (Medicare.gov) for details, as rules vary by state and plan.

Answer: The Medicare Annual Wellness Visit (AWV) is a preventive service covered by Medicare Part B once per year. It's designed to help you create or update a personalized plan to prevent illness and stay healthy. There's no copayment, coinsurance, or deductible for this visit.

Here's what's typically included, based on Centers for Medicare & Medicaid Services (CMS) guidelines:

Health Review: Discussion of your medical and family history, including any new health issues.

Vital Measurements: Checking height, weight, body mass index (BMI), and blood pressure.

Risk Assessments: Screening for risks like depression, falls, and cognitive impairment (e.g., memory issues).

Functional Review: Evaluation of your ability to perform daily activities and ensure home safety.

Medication Review: A list of your current prescriptions and over-the-counter medications to check for interactions or needs.

Personalized Prevention Plan: Creation or update of a written plan that includes:

Recommended screenings (e.g., for cancer, diabetes).

Vaccinations.

Counseling on healthy lifestyle choices (e.g., diet, exercise).

Provider and Social Review: Updating your list of healthcare providers and discussing community resources if needed.

Eligibility and Tips: You're eligible if you've had Medicare Part B for more than 12 months. Schedule it with your primary care provider or doctor who accepts Medicare. If you have questions about your specific coverage or need help finding a provider, let me know!

Answer: I totally understand why you might think calling your insurance carrier directly is the quickest way—it's a valid option for personalized account details.

Convenience and Speed: I provide instant, 24/7 access to general information on topics like Medicare plans, costs, and benefits, without hold times or scheduling.

Impartial Guidance: As a broker, I draw from reliable sources (like CMS) to give unbiased explanations, helping you understand options before you dive into a call.

Answer: Yes, Medicare provides limited coverage for eye exams, but it depends on the type of exam and your plan. Here's a breakdown based on Centers for Medicare & Medicaid Services (CMS) guidelines:

What Medicare Covers:

Original Medicare (Part B): Covers eye exams if they're medically necessary, such as for diagnosing or treating eye conditions like cataracts, glaucoma, or diabetic retinopathy. For example, an exam for diabetic eye disease is typically covered once per year.

Medicare Advantage (Part C): Many plans include routine vision benefits, like annual eye exams for glasses or contacts, but this varies by plan. Check your specific policy.

What Medicare Does Not Cover:

Routine eye exams for prescription glasses or contacts are not covered under Original Medicare. You may have to pay the full cost out-of-pocket.

Items like eyeglasses, contact lenses, or upgrades (e.g., bifocals) are generally not covered unless related to cataract surgery.

Potential Costs for Seniors:

For covered exams, you might still pay 20% coinsurance after the Part B deductible, plus any doctor fees if they're not in-network.

Without supplemental coverage (like Medigap or a vision plan), routine exams can cost $50–$200 or more, which some seniors find expensive. Medicare Advantage plans often help reduce these costs.

Answer: Yes, it's really happening! Based on the Inflation Reduction Act and updates from the Centers for Medicare & Medicaid Services (CMS), starting January 1, 2025, Medicare Part D will cap out-of-pocket costs for covered prescription drugs at $2,000 per year for most beneficiaries. This is a significant change designed to make medications more affordable.

Answer: Why Are You Paying More for Medicare Part B and D?

It's common for Medicare premiums to vary between individuals, and one key reason is your income level. While most people pay the standard premiums for Part B and Part D, higher-income earners may face additional charges. Let me break this down for you, including what IRMAA is and how it's calculated.

Reasons You Might Be Paying More

Income-Based Surcharges (IRMAA): If your modified adjusted gross income (MAGI) is above certain thresholds, you'll pay an extra amount called the Income-Related Monthly Adjustment Amount (IRMAA). This is often why you might pay more than friends with lower incomes.

Other Factors: Differences could also stem from plan choices (e.g., if you're in a more comprehensive Part D plan), location-based adjustments, or late enrollment penalties. However, IRMAA is the most likely culprit for income-related increases.

What is IRMAA and How is It Calculated?

IRMAA is an additional fee added to your Medicare Part B and Part D premiums if your income exceeds IRS and CMS thresholds. It's designed to make higher-income beneficiaries contribute more toward their healthcare costs.

How It's Calculated:

Based on Income: IRMAA uses your MAGI from your federal tax return two years prior (e.g., 2025 premiums are based on your 2023 tax return).

MAGI Definition: This includes your adjusted gross income plus tax-exempt interest, foreign income, and certain deductions.

Thresholds and Surcharges: CMS sets income brackets annually. For 2025, here's a simplified breakdown based on filing status (using 2023 MAGI):

Filing Status Income Threshold for IRMAA Part B Surcharge (Added to Standard Premium) Part D Surcharge (Added to Plan Premium)

Individual $103,000 or less: No IRMAA N/A N/A

$103,001–$161,000 +$69.90/month +$12.70/month

$161,001–$193,000 +$174.70/month +$32.80/month

$193,001–$228,000 +$279.00/month +$52.80/month

$228,001+ +$383.00–$419.00/month (varies by bracket) +$72.90–$79.70/month (varies by brack

Answer: I truly enjoy providing them with answers that meet their specific needs. I am fulfilled knowing they have chosen the right carrier and their medical services needs are being met.

Answer: I understand your frustration—it's disappointing to be denied coverage after contributing to Medicare for years. Let me explain why this can happen and what your options might be. Medigap plans are offered by private insurance companies, not the government, so their rules differ from Medicare itself. Here's a clear breakdown:

Why Denials Based on Health History Are Legal

Medigap vs. Medicare: Original Medicare (Parts A and B) is guaranteed and doesn't consider your health history, but Medigap policies are supplemental insurance sold by private insurers. Under federal law (as outlined by CMS), these companies can deny coverage or charge higher premiums based on health factors outside of specific enrollment periods. This is allowed because Medigap is not part of the core Medicare program you paid into.

Open Enrollment Period: During your 6-month initial window (starting the month you turn 65 and enroll in Part B), insurers cannot deny you a Medigap plan or use your health against you—it's a guaranteed issue period. If you applied outside of this, denials are possible and legal, as states regulate but don't always prohibit underwriting.

Legality: This practice complies with the Affordable Care Act and state insurance laws, which balance consumer protections with insurer risks. It's not ideal, but it's how the system is structured to keep premiums affordable for everyone.

What You Can Do Next

Check for Guaranteed Issue Rights: If you qualify (e.g., due to losing other coverage, moving states, or your plan being canceled), you might still get a Medigap plan without health questions. Review your situation on Medicare.gov.

Explore Alternatives: Consider Medicare Advantage plans (Part C), which often include additional benefits like vision or dental and might not require health underwriting during enrollment periods. You could also look into state high-risk pools or other supplemental options.

Appeal or Shop Around: Contact the insurer for an appeal or reasons for den

Answer: Medical Care Overseas with Medicare

Planning a trip abroad is exciting, but it's smart to know how Medicare handles healthcare needs outside the U.S. Here's a concise overview based on Centers for Medicare & Medicaid Services (CMS) guidelines:

Original Medicare Coverage (Parts A and B): Generally, it does not cover medical care outside the United States. This includes routine care, hospitalizations, or emergencies in most foreign countries.

Limited Exceptions:

Emergency Care in Canada: If you're traveling between Alaska and another U.S. state, Medicare might cover inpatient hospital care in a Canadian hospital if it's the closest facility.

U.S.-Border Hospitals: For those near the Mexican border, Medicare could cover care in a Mexican hospital if it's the nearest one and you're in the U.S. at the time of the emergency.

No Coverage for Other Travel: Even for cruises or trips to Europe, Asia, etc., you're typically on your own for costs.

Medicare Advantage (Part C): Some plans offer limited international coverage (e.g., up to a certain number of days or dollar amount for emergencies). Check your specific plan details, as this varies widely.

What This Means for You:

You could face high out-of-pocket costs for medical care abroad, which might not be reimbursed. For example, hospital stays, doctor visits, or medications could add up quickly without travel insurance.

Always carry your Medicare card and other ID, but don't rely on it for international care.

Recommendations to Prepare:

Get Travel Insurance: This is highly recommended to cover medical emergencies, evacuations, and other travel-related issues. Look for policies that include health coverage.

Plan Ahead: Before your trip, review your Medicare Summary Notice or contact your plan provider. Consider international health insurance options through private insurers.

Enroll in STEP: Register with the U.S. State Department's Smart Traveler Enrollment Program (STEP) for travel alerts and emergency assis