Tony Carlton, Medicare Insurance Agent

Answer: Thank you for this question. This is probably the most important question for Medicare Beneficiaries going into 2026.

My recommendation for you and all Medicare Beneficiaries is to have a 'Annual Review' of your plan and the upcoming options for the coming year. I implore all Beneficiaries t review the upcoming Formulary changes for your prescriptions, doctors, and hospitals.

Because of the changes that were made in 2024, we are still feeling the effects and need to plan accordingly. Many plans around the country have been ended. So, replacing your plan is essential. For example, in the state of Vermont there is only one Medicare company available because every other company found it too stressful to remain and offer coverage. Now if your plan has been Terminated you have the opportunity to return to Original Medicare on a Guaranteed Issue basis. There will be no Pre-Existing Conditions or Underwriting for your policy.

So, find yourself an independent agent who can see the whole landscape of Medicare. A good agent is an invaluable source of expertise whose service can guide you to the plan that will save you money and save your health.

Thanks again and God bless!

Answer: Well, thank you for this question. Medicare choices can be very complicated. There are so many factors that I consider when doing a compliant Medicare presenting.

While premiums are a major factor, premiums are not the only factor to consider. So, to say that you've made a "mistake" by choosing a MedSup would be a premature diagnosis.

The good news is that you do have options. Option one is to shop around. But to streamline and simplify the shopping I would contact an independent licensed agent who can see all of the plans available in your area. Showing you the plans available and answering your questions about cost, coverage {for Medicare Advantage ~ In-Network vs Out-of-Network}, your health needs, prescription costs {formularies}.

Or you can shop for a new MedSup plan at a lower cost. You can do this because ALL MedSup Plan G's must cover the 20% of Part A & B costs that Original Medicare does not cover. Just know that if you choose to move to a Medicare Advantage plan with a $0 premium, that there is an annual Maximum Out of Pocket that most Medicare Beneficiaries don't know about.

And a word of caution because you travel, if you do choose to enroll into a Medicare Advantage plan, choose a PPO. Medicare Advantage HMO's have no Out-of-Network coverage. So, this means that if you are out of your service area or Network, that you will incur the full cost of a hospital stay.

Thanks again for this simple but complex question and God bless!

Answer: Thank you for your question. This is a wonderful question and thank you for being willing to step-up to help your parents decide on the Medicare plan that fits them.

Short answer is YES! You most certainly can meet with a Medicare advisor on behalf of your Mom and Dad. There is one stipulation, you must be able to provide written proof as the Medicare Proxy for them, if called upon. Also, a verbal authorization is sufficient if meeting with an advisor via phone.

Now the reason that I think this a wonderful is because as our parents age, especially past age 80, their mental capacity seems to diminish. So, I tell my clients that their children, niece, nephew or someone younger who loves them should know what Medicare plan they are on and why. This is because unlike group work benefits, Medicare is customized health insurance. And the wrong choice can be very costly financially and/or healthwise.

Thanks again and God bless!

Answer: That's a wonderful point. Thank you for the opportunity to clarify an under-covered subject.

You have been hit with an extra charge because of your annual taxable income from the last 2 years. Medicare Part B {commonly called, doctor coverage} and Medicare Part D {Prescription Drug coverage} premiums are increased at 5 different thresholds that determine your premium increase {penalty}. The increase is based on your Modified Adjusted Gross Income {MAGI} Bracket and that determines the Part B & Part D Surcharge.

For Individuals the range is:

Individual

$106,000.01 - $133,000

$74.00 (Part B) + $13.70 (Part D)

Individual

$133,000.01 - $167,000

$185.00 (Part B) + $35.30 (Part D)

Individual

$167,000.01 - $200,000

$295.90 (Part B) + $57.00 (Part D)

Individual

$200,000.01 - $499,999.99

$406.90 (Part B) + $78.60 (Part D)

Individual

More than $499,999.99

$443.90 (Part B) + $85.80 (Part D)

For Married couples who file jointly the range is:

Married Filing Jointly

$212,000.01 - $266,000

$74.00 (Part B) + $13.70 (Part D)

Married Filing Jointly

$266,000.01 - $334,000

$185.00 (Part B) + $35.30 (Part D)

Married Filing Jointly

$334,000.01 - $400,000

$295.90 (Part B) + $57.00 (Part D)

Married Filing Jointly

$400,000.01 - $749,999.99

$406.90 (Part B) + $78.60 (Part D)

Married Filing Jointly

More than $750,000

$443.90 (Part B) + $85.80 (Part D)

If I may ask and answer your unasked question... Is IRMAA avoidable?

To avoid IRMAA there is nothing you can do to reduce it immediately. This is so because there is a 2 year "Look-back" on your MAGI. So, with proper planning you may be able to avoid the IRMAA in 2 years and beyond. Most Medicare agents don't know how to avoid IRMAA and most Financial Advisors know nothing about Medicare. You'll need to reach out to an expert who knows how both lanes can merge together for your benefit.

Remember, there is a good and honorable solution for every good thing under the Sun.

Again, thanks for that under-asked question and God bless!

Answer: Thank you for your question. I think that's an excellent question.

So, my observation is that there is a group of what I call "Young Guns'. These 'Young Guns" are all under 40 and have found their niche in the Medicare space. I have learned much from these men and women on a professional level about Medicare and 'Best Practices' of running a Medicare agency.

While the average age of an insurance agent is 60 or 61, it is great to see young men and women who will have a long career in the Medicare space.

And Medicare is so complicated with so many changes on an annual basis that having young, alert eyes helps to keep clients up to date on the latest things.

Well, that must seem like quite an endorsement for working with a younger Medicare Advisor. But let me say this about us "Seasoned" Advisors", we have seen the of our advice on our clients. So, we know and can perhaps appreciate first hand just how valuable the 'care' part of 'healthcare' is on your life.

We have seen up close how our plan advice impacts your health over the course of years.

So, it really does come down to expertise, care and independence.

I would want to work with advisors who shop for a plan the same way as they would for their Mom or Dad. No matter the age.

Thanks again and God bless!

Answer: Thank you for this question.

As an independent Medicare agent I find the biggest frustration is the same as for the Medicare Beneficiary... CONFUSION!!!

There are so many moving parts, plans and even vocabulary that is so totally different from what we know during our working lives. The uptake of new information is usually tainted by the paradigm of what health insurance was like previously at your job.

So, when you retire it is natural to believe that Medicare is just a health insurance plan for retirees. But unlike the group coverage of your work years, Medicare is like buying a custom made outfit. And that outfit needs to be refit on an annual basis because of changes to Formularies, Networks and plans.

Getting new Beneficiaries and my clients enough information to make an informed decision is a responsibility that I take seriously in the extreme. Also, I know that the advise that I give about plans can help save someone's life. I hope and pray that I can have a great and positive impact on providing advice that creates health and wealth in all the states that I serve.

Thanks again for your question and God bless!

Answer: Excellent question! Thank you for the opportunity to answer this very important question. Medicare Part D has changed so much since 2024. For one the Donut Hole has been eliminated. Second, the True Out Of Pocket maximum was reduced from $8,000 to $2,000. In 2026, that maximum will go up to $2,100. So, plan accordingly.

The impact of this is that the formularies cost sharing has shifted and many Part D providers have changed plans and/or left unsustainable service areas altogether. These impacts should begin to end in 2026 as the new Big Beautiful Bill takes effect.

One huge change is the Most Favored Nation pricing for medications in the United States. Previous to this year, foreign countries got Most Favored Nation pricing but Americans did not. So, Medicare Beneficiaries were paying the freight for countries around the world. That will not be the case in 2026.

The impact on seniors who take many medications or Tier 3,4 and 5 meds should reduce costs greatly. I look forward to see our country and those in their 'Golden Years' receive the best that America has to offer next year and beyond.

Thanks again and God bless!

Answer: I enjoy helping seniors shop for a plan that fits their healthcare and budget needs. Medicare is such a complicated program and it changes very year, that I truly do not know how anyone without the tools and expertise of how it works, how anyone would choose the plan that fits them best.

Medicare IS NOT one-size-fits-all health insurance. Helping someone get the plans that fits them. Knowing that someone is trusting me and my expertise to help them shop for THE plan that is affordable and has their providers covered also.

That trust is something that I've never experienced before in my professional life. The wrong plan can bankrupt someone or worse. I have seen the right plan save lives. I am thankful to be able to give guidance that impacts lives so greatly. I enjoy that beyond measure.

Thanks again for this question and God bless!

Answer: Excellent question! Thank you for the opportunity to share my experience of how the Medicare program works when the "rubber meets the road". Two things that I consider above all is the 'Star Rating' of a Medicare Advantage company and Maximum Out-of-Pocket {MOOP} of their specific plan.

The Star Rating is given annually by the Medicare Beneficiaries who have lived that plan. They rate the plans benefits, services and networks. And the rating is from 1 - 5 Stars. A company must maintain a 3 Star rating or above to operate in a service area. If the rating drops to 2.5 for 2 consecutive years that company cannot do business in that service area.

Also, companies that strive for 5 Stars and they may not achieve that goal but those companies tend to deliver better services and doctors than those who hover around 3 Stars.

So, while you may hear your neighbor rave about his or her monthly 'Food Card' benefits, ask about the Star Rating. And while you're at it, ask about how much their plan can cost on an annual basis. This number is their MOOP. This can vary greatly from plan to plan. So, those plans that offer great ancillary benefits tend to have higher MOOP's. And that is a cost that you will here about as a complaint. But with the help of an independent agent, you can avoid many of these pitfalls.

Thanks again and God bless!

Answer: Thank you for your question. And to get right to the point... it depends. How's that for succinct expertise? But really, all the changes from 2026 to 2026 mean that this year more than most requires a thorough review of your plan to see if it will even be offered in 2026. So, pay attention to all correspondence from your current carrier. Second, eve if your plan will continue into 2026, I strongly recommend that you review how your 2026 plan will stack up against other plans that will be offered in your area in 2026.

Especially look for changes to your Prescription Drug Plan formulary. These formularies change every year and even if you are covered by a Medicare supplement plan, your should review the estimated cost of your meds to see if there is, perhaps a lower cost option.

If you are on a Medicare Advantage plan you should review all of the above AND the ancillary benefits like dental and vision. I recommend this because if you anticipate needing a good amount of dental work in 2026, well you may lean toward a plan that offers much more dental. The same goes for vision benefits.

Consider all of this while making sure that your doctors and local hospitals are 'In-Network' for whatever plan you choose. So, if this task seems a bit much then I wholeheartedly recommend working with a licensed, CMS Certified Medicare agent.

Thank you and God bless!

Answer: Thank you for this question. So many times we agents who help seniors with their Medicare choices get stuck in acronym quicksand. CMS, HMO, PPO, MAPD, PFFS, PDP MOOP... WTH?

Anyway, to answer the most common types of Medicare Advantage {Part C} plans, there are 2 basic types: PPO and HMO.

Most people sign up for either of these 2 plans based on their needs and budget. To explain the acronyms that apply to the 2 most common Medicare Advantage plans, HMO means a Health Maintenance Organization; PPO means Preferred Provider Organization.

An HMO is a plan that is designed with generous ancillary benefits because there is no Out-Of-Network coverage. An HMO only provides coverage for doctors and hospitals that contract with that particular company. Also, generally there is only coverage within a local area {statewide}.

A PPO is a plan that has In-Network and Out-of-Network coverage. So, any doctor or hospital that accepts Medicare must accept your plan coverage. Now, what's the catch... well, not every doctor and hospital will be In-Network. And if a for those service providers who do not have a contract with the Medicare Advantage company, they are Out-of-Network and there may be a higher cost to see those providers. You will have coverage at every hospital and doctor who takes Medicare... nationwide!

Thanks again for your question and God bless!

Answer: Excellent question, thank you for the opportunity to shed some light on these questions. A 'Scope of Appointment' {SOA} is a Center for Medicare and Medicaid {CMS} requirement to discuss Medicare Advantage and Prescription Drug Plans. While it does list other products as well the primary focus is Medicare Part C {Medicare Advantage} and Part D {Prescription Drug Plans}.

And the second question regarding Call Centers is excellent also. Inbound calls whether to a call center or an Independent agent require a SOA but there is no waiting period and it can done when the inbound call is received.

So, yes SOA's are perfectly normal and a good industry practice to protect Medicare Beneficiaries and agents alike.

BTW, the SOA's must be stored for 10 years just in case a of dispute about what permission the Beneficiary gave for the topics, products and solutions to be discussed.

Thanks again and God bless.

Answer: Thank you for your question today. For as long as I have been in the insurance business there have been questions about Medicare and Social Security. BTW, I started in 1990.

So, the short answer is yes regarding whether Medicare will be more expensive over time. And NO regarding whether Medicare will be unsustainable.

Medicare, as complex as it is has many things going for it. But way back in the 1990's we knew that there was a Baby Boomer Bubble of 75 Million future Medicare and Social Security Beneficiaries that would strain the system for a period of about 30 or 40 years. So, that many beneficiaries all aging and needing healthcare puts a stress on the supply, cost of care and medications. Living healthy is a great answer. But inflation in the cost of healthcare for my fellow Baby-Boomers is baked into the cake. But the good news is that earlier this year Elon Musk and his DOGE team discovered over $7 Trillion of Fraud, Waste and Abuse in both Medicare and Social Security from the previous 4 years. This is "good news because if that money can be 'Clawed-Back" that would go a long way to reduce expenses for beneficiaries and reset the sustainability of both Medicare and Social Security.

There's also been a change in the compensation model of the Pharmaceutical companies; the prices of drugs charged in America and the Pharmacy Benefit Manager {PBM}. Previously, the more that your medications cost the more the PBM got paid. That is not conducive to getting meds at the lowest cost.

Also, if economic growth of our country can be reset to an inbound growth model as seems to be occurring, we can know that costs may go up but your Social Security and other retirement assets will increase even more.

So, I am looking forward to what the next few years bring to our country and specifically the well earned Golden Years that Baby-Boomers were promised by working hard and playing by the rules.

Thanks again and God bless.

Answer: Thank you for the chance to answer this important question.

The short answer is yes. But I am always wary of the type of Medicare Advantage plan that I recommend to my clients. There are two types of plans. The plans that offer the highest benefit levels are Health Maintenance Organizations {HMO}. These plans have coverage In-Network only. There is no coverage for hospitals or doctors outside of the contracted network.

So, if you are in a rural area and are considering an HMO, you need to confirm, confirm and confirm that your local hospital and your doctors are In-Network. Also, regarding most HMO's, there is no coverage outside of the service area, i.e, the state, except for emergency room coverage. So choose wisely.

Now, the other type of plan is a Preferred Provider Organization {PPO}. A PPO has In-Network and Out-of-Network coverage. This means that any doctor or hospital that accepts Medicare must accept your plan.

SO, when you hear a family member, friend or doctor say that this or that company does not work with/for them, know that they likely have an HMO.

What's the catch of having a PPO? Less generous benefits {food card; Part B Giveback; MOOP} are the typical trade-off for having ubiquitous coverage... anywhere, anytime.

Thanks again and God bless.

Answer: Thank you for the chance to give you some accurate information.

Unlike a call center, Medicare.gov, state volunteers or an agent that represents one company, by calling your agent on MedicareAgentsHub.com you are getting an independent agent who can see every plan in your area and the costs of that plan to you.

We can see the whole Medicare landscape and shop the same way as you would.

Rest assured that on the other side of the call to a Referral number is a Medicare expert who brings expertise and commitment to keeping our clients healthy in their body and their wallet.

Thanks again and God bless.

Answer: Thank you for your question. That's a good question. So, when you meet a licensed, independent Medicare advisor you have met someone who is an expert in a very complicated field.

The way that independent advisors/agents get paid is by commissions, which for Medicare Advantage {Part C} and Prescription Drug Plans {Part D}, is set by the Center for Medicare and Medicaid {CMS... I know, where's the other M? LOL}. Commissions for Medicare Supplement {a.k.a - MedSup or Medicgap} are set and paid by the individual MedSup company.

And I can truly say that, because of the freedom of choice and tools that independence provides, we don't get paid more or less for recommending one company or plan over the other.

Think about it this way, the agent needs clients not just for this year but for years to come. Hence, we need to have our clients healthy and with the plan the fits your health and budget now and on an annual basis.

A healthcare plan that provides a food card or some other incentive is not a higher priority than a plan that covers your doctors, medications and hospitals at a cost that you can afford.

Also, the Star Rating of a Medicare Advantage plan is an important consideration. Because that rating is given by the Medicare Beneficiaries.

So all that being said, NO being paid by commission does not affect the plan recommendation for most independent Medicare advisor.

BTW, we must complete an annual training, through CMS called AHIP. We must pass this coursework with a score of 90% or we cannot sell the products for the next 12 months.

As someone who was a Stockbroker in the 1990's, I know that this a rigorous trial to stay current with the many changes that occur in Medicare annually. No other state advisor or volunteers go through this or have access to all the ways to find a plan as your local Medicare advisor. You are in the hands of an expert who cares about you before you arrived at his/her door. Find one who you like and trust... and Good bless.

Answer: Thank you for the question. Medicare is too complicated for such an important need in retirement, so I'll try to keep it simple.

How often you can change my Medicare plan depends on whether you have Original Medicare with a Medicare Supplement {a.k.a. MediGap plan} or a Medicare Advantage {Medicare Part C} plan.

Starting with MediGap Insurance, because this is privately contracted, you can make a change to this type of policy as often as you want. While knowing that you may need to undergo health underwriting each time. And so your health will be considered with every attempt to get a new policy from a different company. Most people only make a change after a premium increase. This is because a Plan G from any company must cover the 20% that Original Medicare does not cover.

Now regarding Medicare Advantage changes, under normal conditions this can usually be done once a year. The usually time is during the 'Annual Enrollment Period' {October 15th - December 7th}. But like seemingly all things government, there are exceptions... such as during a 'Special Enrollment Period' {SEP}. These SEP's are declared after natural disasters, i.e. hurricanes; floods; or tornadoes. These SEP's are for people in the area who have been impacted by these events and they are given the opportunity to change plans.

Finally, there is one more opportunity to change your Medicare Advantage plan that most people never realize. This opportunity goes under-used because Agents cannot outwardly market for this, as per CMS guidelines. That window is annually from January 1st through March 30th. This window is called the 'Open Enrollment Period'.

Hey dear Medicare questioner, I know this is a long and somewhat convoluted answer to your concise question but this is the shortest most concise answer that in my expertise, I can give.

Thank you for the opportunity to bring some clarity to this subject and God bless.