Tim J Harris, Medicare Insurance Agent

Answer: If you have been diagnosed with a serious illness, you most likely will not pass Medical Underwriting to be accepted into a Medicare Supplement (Medigap)Plan.

The only point where Medicare Supplement (Medigap) Plans are guaranteed issue are when you were first eligible for Medicare.

Answer: The Maximum Out-of-Pocket Drug Cost (now $2100 for 2026) is the point where, after you have spent $2100 on prescription drugs during the current year, your prescription drugs are 100% covered for the remainder of that year.

Here is something important about Medicare Advantage Plans that include a drug plan and stand alone Part-D drug plans. Before you enroll in either, be certain that all the prescription drugs you take are IN that carriers formulary. Only drugs in their formulary are covered by the plan and only the out of pocket costs you pay are included in the $2100 maximum out of pocket.

Answer: If you are on a Medicare Advantage Plan, CMS regulations allow you to upgrade to a 5-Star Medicare Advantage Plan at any time.

This Special Enrollment Period (SEP) is different from the Annual Enrollment Period (AEP) and the Open Enrollment Period (OEP).

Answer: HANG UP!

If you did not give someone permission to call you on the phone about Medicare, they are violating CMS regulations if they call. In this day and age of AI, it is best to say nothing, just HANG UP. Anything you say could be recorded and manipulated using AI.

If you see a TV ad about some amazing Medicare benefit and are curious about it. DO NOT call the 800 number on the TV. Call your agent/broker and ask about it. Your agent/broker is familiar with benefits and can help you.

Bottom line, find a local agent/broker you like and make that person your sole contact for all things Medicare.

Answer: You can change from one Medicare Supplement (Medigap) Plan to another at any time, but you most likely will be subject to Medical Underwriting.

Since Medicare Supplement (Medigap) plans are guaranteed renewal, as long as you pay your premiums, you can stay on the plan you have.

If you want to change, the carrier you want to change to can review your medical history to see if they want to accept you.

If you do make a change, DO NOT CANCEL your existing Medicare Supplement (Medigap) Plan until you have it in writing that you have been accepted into the new plan.

Answer: Being a frequent traveler is one of the many things you should discuss with your agent/broker when weighing your Medicare options.

Original Medicare with a Part D Plan will allow you to see any healthcare provider in the USA who accepts Medicare.

Original Medicare with a Medicare Supplement (Medigap) Plan & a Part D Drug Plan would also allow you to see any healthcare provider in the USA who accepts Medicare without being subject to all the gaps in Original Medicare.

Medicare Advantage Plan travel benefits will vary by carrier. There are some who have large networks across most of the USA and have benefits in their plans that allow you to utilize in network providers while you travel.

Answer: You can change from a Medicare Advantage Plan to Original Medicare during the Annual Enrollment Period (Oct 15th thru Dec 7th), during the Open Enrollment Period (Jan 1st thru Mar 31st) or possibly a Special Enrollment Period.

You will need to enroll in a Part D (Prescription Drug Plan) within two months to avoid the Late Enrollment Penalty.

There are coverage gaps in Original Medicare, some can be quite expensive if you are hospitalized or suffer a major medical issue. Having only Original Medicare is risky.

I always advise clients to have either a Medicare Advantage Plan or a Medicare Supplement (Medigap) Plan.

Answer: When you are first eligible for Medicare, there is a short guaranteed enrollment window for Medicare Supplement (Medigap) Plans. If you miss that opportunity, you may be subject to medical underwriting if you wish to enroll in a Medigap Plan later. So it is best to be fully informed of all your options (both Medigap and Advantage options) in order for you to make the best decision for your medical care.

Answer: 1) Medicare will never call you (unless you have an appointment or a call back, that you initiated.) If someone calls claiming they are with the government Medicare, HANG UP! If you are concerned that Medicare may really need to talk to you, call 1-800-MEDICARE and ask about it.

2) HANG UP! Any licensed agent who calls you to talk about Medicare must have your permission. So, if someone calls trying to sell Medicare or asking for personal information, and you don't know them, they obviously don't have permission to call you. So HANG UP! Don't say anything, remember anything you say, they can record and twist around to use to defraud you. Don't give them anything, not even a hello. HANG UP!

Know your local agent. Your local licensed Medicare insurance agent is the only person you should give your Medicare number and discuss your Medicare plans with. Find an agent you like and trust and stay with them.

Answer: No, agents are paid a commission amount set by Center for Medicare Services (US Govt) for enrolling someone in a Medicare Advantage plan. The amount is the same no matter what plan the client selects.

Answer: Was the specialist in network and did you get a referral from your primary care doctor (if required)?

You can do a number of things:

1) Request an organizational determination.

2)File an appeal

3)Request a Single Case Agreement

4)Request a Continuity of Care Exception

5)File a Complaint with Medicare

Keep in mind, you are never stuck for long with any Medicare Advantage Plan, if you are not happy with you plan, you can switch to another plan at the next available enrollment period.

Answer: I like to help people... and it does not hurt that I can make a living doing it. One at a time, I confirm that a person is receiving the Medicare benefits he or she is entitled to. While Medicare may not be as complicated as some believe it to be, it is still a maze that has serious costly pitfalls if someone does no have the correct coverage.

Answer: Generally, with an HMO, there are no benefits outside the network... but there are exceptions... and it can be complicated. Exceptions may include emergency situations, continuity of care, a specialty that the HMO does not have in network, etc. Read your plan's summary of benefits and other plan details, then call the customer service line to inquire. Also, there are Single Case Agreements where an out of network doctor obtains authorization to to treat a specific person for a specific condition for a specific period of time with in-network benefits. You have to ask.

Answer: Well, I learned in high school economics class that "there is no such thing as a free ham sandwich". Yes, it might be FREE to you, but somebody had to raise the pig and grow the wheat.

Medicare Advantage plans may be "Zero Premium" to you, but you paid taxes (along with everyone else) and you pay a Part B premium (along with everyone else) so the government can pay the insurance companies to provide the Medicare Advantage plans.

I wouldn't call it "clever marketing". When I discuss options with a person who is turning 65, we look at the true annual out of pocket cost of having an Advantage plan VS a Medicare Supplement (MediGap) plan. The premium amount is only one part of the equation.

Answer: People are living longer and medical care is always improving, those two factors combined increase Medicare's overall costs each year. I believe we will see the elimination of PPOs and a reduction of additional benefits like dental/vision/hearing, OTC allowances and giveback plans as insurance companies cut costs. We will probably also see a regular annual increase in the Part B premium and possibly even payroll taxes for workers as the government works to fund Medicare.

Answer: In my opinion, the biggest disadvantage of Medicare Advantage plans is being restricted to a network in order to receive maximum benefits with a PPO and benefits at all with a HMO. With that said, most people who had medical insurance prior to age 65 are already accustomed to using a plan with a network. The twist with Medicare Advantage plans is always having to be vigilant, because medical providers seem to come and go from networks. Medicare Advantage plans are no perfect, but they do protect you from the unlimited potential costs of only having traditional Medicare Parts A and B.

Answer: Most Medicare Part D (Prescription Drug Plan = PDP) plans have Repatha in their formulary. All prescriptions you currently take should be checked to be sure they are all on the formulary of the specific plan you are considering. Drug names and formularies can get tricky, please don't go this alone, a local Medicare agent is best suited to check this for you.

Answer: I good local Medicare agent should help from the first phone call, through plan decisions, enrollment and for as long as your parents have their Medicare plans. Medicare is individual plans and an annual renewal. Your agent should support you and your parents every step of the way.

Answer: Find a local Medicare agent you can trust. Many offer "Medicare 101" seminars or can sit to discuss with you one on one. It's really not as complicated as it seems.

Answer: 1) Find a local Medicare agent you are comfortable with.

2) Provide the agent with your parents preferred Doctors, Hospitals and other providers.

3) The agent can help by providing you with plan options that meet your parents needs.

Answer: Medigap rules can get surprisingly tangled, and your situation—where your previous insurer disappeared and never notified you—sits in one of those gray areas where the intent of the law and the administration of it don’t always line up neatly.

My suggestion is to speak with a Medicare agent in your local area because the specifics of your situation may determine the what you should do.

Answer: A local Medicare Agent has first hand knowledge of the available plans and provider networks in the area where you live. This knowledge is essential to provide you with the best Medicare plan that takes care of your needs.

A local agent is here, where you are, available to answer your questions and help if an issue arises, something an anonymous person in a 1-800 call center cannot provide on an ongoing basis.

...and did I mention it's free?