Tonya White, Medicare Insurance Agent

Answer: Yes, Repatha is covered under most, but not all Part D plans. It will be important to compare if and how it's covered in your service area. Medicare's Part D deductible will likely apply unless your plan is generous to waive it. During the deductible period you will pay more for it but once the deductible is met you'll either have a basic copay or coinsurance depending on your plan. The most you will pay for Part D medication costs during the calendar year is $2,100, including the deductible and your copays/coinsurance.

Answer: Now this is a very interesting question, and I'm curious as to the person who submitted this. What's a common trick in Medicare marketing that hides restrictions on doctor choices? So here's what you want to ensure when it comes to your selection of doctors and whether and how they are covered by your plan. It depends on the type of plan that you have. If you have a Medicare Advantage plan, most of them are Medicare Advantage prescription drug plans where the drug plan is part of the same plan. There are HMO plans and there are PPO plans, regardless of whether it's an HMO or a PPO. Those are still network plans.

With an HMO, you must stay in network. That has nothing to do with how the plan is marketed; it's how the plan is designed. You have to stay in network. If it's a PPO plan, you do have more flexibility, and you can go out of network, but it will be at a higher cost to you. So you want to ensure your doctors are in network either way. Now again, with the PPO, you can go out of network, but it will be at a higher cost. So I don't necessarily recommend that.

You also want to ensure that any and all specialists that you see are part of the same medical group and network that your primary care physician belongs to because everything is going to be based on your primary care physician and an HMO plan. It's slightly different with that PPO plan because, again, you can go out of network, and as long as the doctor is in network, you can still see that doctor, and it will be considered an in-network visit on an HMO. You do not have that same level of flexibility.

So there are doctors who are just affiliated with one medical group, and then there are doctors who are affiliated with multiple medical groups. If your doctor is affiliated with multiple medical groups, you need to decide which medical group you want to be associated with for your specific plan. All of the specialists that you see have to belong to that same medical group. It can't be a situation where your doctor has three different medical groups, and you can see any and all specialists from all the medical groups and be considered in network. The in-network charges will be based on the specific medical group that your doctor is affiliated with.

So you want to make sure that if they have multiple affiliations, you are choosing the one. If you are seeing various specialists, you are choosing the one that most, if not all, of your doctors belong to. This is on a PPO; again, on an HMO, you are restricted to the network. So there's no marketing ploy, no marketing tactic. It's just something that is based on the structure of how the plan is designed. It is up to you to make sure that your doctors are going to take the plan that they're contracted with, that your doctors are in network—not only your primary care physician, also known as PCP, but any and all specialists.

That's what the Medicare Advantage plan is. There are also Medicare supplement plans, Medsup, also known as a Medigap plan. Now with these plans, you can see any doctor as long as a doctor takes Medicare. There are a few exceptions to that, but that for the most part is the case. There is a large medical group—I won't name any names—but they do everything internally. They do not take Medicare supplement plans, so that would be an exception. Even though they see Medicare patients, they have their own Medicare plans designed that doctors are employed by that medical plan employed by the insurance company.

So that's a different variation. But in most cases, a doctor who takes Medicare will take a Medicare supplement plan. There's no networks of doctors you have to worry about there. You can again see any doctor as long as they take Medicare. I hope that answers your question and alleviates any concern related to any trickery. There really is no trickery around doctors and doctors' networks. It just really depends on how your plan is structured.

You can access your summary plan document. It would have the type of plan that you're enrolled in. It should say on your card as well whether it's a Medicare Advantage plan, HMO plan, Medicare Advantage plan, PPO plan, or a Medicare supplement plan. Those are basically your choices when you are on Medicare, and the person who helped you enroll should be able to assist you with any further questions specific to your doctors or your doctors that work with you.

And I hope that builds any concern around any potential trickery regarding how plans are marketed. Have a great day. Bye-bye.

Answer: This question came in: I'm on Medicare and recently declared bankruptcy due to medical bills. How will this affect my coverage and options going forward?

Your financial status really doesn't affect your Medicare eligibility or your options. As long as you are continuing to pay your Part B premiums to the government, you're good. Now, you'll likely already have paid into Part A of Medicare your entire working career. It takes 40 credits, or ten years of working history, to be able to do that. And once you stop working, you no longer are contributing to Part A premiums.

Part B, though, does not start until you activate it, either at age 65 or when you otherwise become eligible for Medicare or come off of a group plan. So as long as you are making your Part B premiums to the government, they don't really care about your financial status, your bankruptcy status, or anything like that.

As long as you're also paying your premiums to the insurance company that you may have, whether you have a Medicare supplement plan and standalone prescription drug plan combination or, in lieu of that, if you have a Medicare Advantage plan, as long as you're contributing your premiums to the plans, then you are fine. They don't look at your financial history. They don't look at your bankruptcy or anything like that.

Now, you could also have a Medicare Advantage plan that doesn't have a premium at all, in which case you wouldn't even pay a monthly premium to that organization, as long as you don't have a late enrollment penalty based on enrolling late into Medicare.

I hope that answers your question. Your financial status and your bankruptcy status have nothing to do with your eligibility for Medicare. The options on Medicare that you have available to you are all right. Have a great day! Bye!

Answer: A question came in. An agent asked me to sign a scope of appointment before we could discuss my Medicare insurance or Part D plan. What is an SOA? Is this normal, and are our call centers exempt from this practice?

So first, what is an SOA? An SOA is a scope of appointment form. And as we will see here, it is actually a government-required form. Is this normal? Yes, it is normal.

Now, who is required to perform or obtain a scope of appointment? It's going to be an independent agent or broker. They are required by the federal government, CMS, to ensure that they have this form that simply allows them to discuss Medicare options with you. And so you'll have to check all the boxes that apply, and they can only discuss those items that you have checked off. And then you sign and date.

If you are not able to make decisions on your own, then your power of attorney, medical power of attorney, would sign the form and date it.

Because let's see here who is not required to provide a scope of appointment form. That would be call centers. So your question is, why are our call centers exempt from this practice? And yes, call centers are exempt from this practice because you are making an inbound call to the call center. They are basically considered order takers and not truly marketing their services.

And even if you call in to your agent or broker, they still have to obtain that form, the scope of appointment form, because it is still considered a marketing practice, even if you are initiating that call to them. They do have to keep this form on record for ten years as well, which is quite a long period of time.

So that answers your question of what the scope of appointment form is all about, why you have to complete it. If you refuse to complete it, you can certainly do so, but they will not be able to speak with you. They will have to direct you to 1-800-MEDICARE to speak with Medicare or some other type of service or call directly to the insurance company. They will not be able to assist you without that form in place.

All right, have a great day. Bye-bye.

Answer: An under-rated benefit of having Original Medicare is that you can see any doctor that takes Medicare and that it covers approximately 80% of many services. The downside is there is no out-of-pocket maximum and you could be on the hook for significant medical bills if you do not have a Medicare Supplement and Stand-Alone Part D Prescription Drug Plan. Original Medicare does not cover medications.

Answer: So the question came in: Do Medicare Advantage plans cover home health care? The answer is yes, they do. First, there would be an assessment, and of course, your doctor has to be in the process for this. They can schedule an assessment to determine whether you qualify to receive home health care.

If that is the case, typically, the situation would be that you would be homebound. Most of the time, this happens post-surgery or post-hospitalization. You may not be able to come into the doctor's office to receive services such as checking vitals, changing bandages for wound care, or things of that nature, where they would send out a skilled practitioner.

It is not somebody coming in to help with cooking and cleaning and doing all of those things, but it can cover things such as if you are not able to perform one of the activities of daily living, like feeding, toileting, bathing, grooming, and things of that nature. There are six activities of daily living, so if you're not able to perform those, then you may qualify for someone to come in to help you receive those services on a part-time or intermittent basis.

So it is not long-term care. Just to be very clear, Medicare does not cover long-term care, but they will cover short-term rehabilitative types of care. So it could also include physical therapy. If you're not in a skilled nursing facility or something like that post-surgery, it could apply.

So I hope that answers your question, and keep them coming. Take care. Bye-bye.

Answer: The donut hole was eliminated in 2025. There is a max out-of-pocket for prescription drugs for medications in the plan's formulary, in 2025 that number is $2,000 and in 2026 it is $2,100.

Answer: I can understand your frustration. There is not a straightline answer to your question, and the Social Security Administration does not help you strategize on the best time to take Social Security but there are others, such as myself, who are financial advisors and conduct a Social Security Analysis for clients to help determine the best time to take it and there are many factors. Some of the factors that come into play are... are you single, married, ever been married, divorced, if divorced - how many years of marriage and since divorce, are you widowed, who was/is the primary breadwinner, what do each of your statement look like, are there dependent children, etc etc etc.

Answer: Typically the dental coverage in most Medicare Advantage plans are dental HMO plans and they do often have limited coverage. Many stand-alone dental plans also have limited coverage. Typically the most robust dental coverage are on employer group plans as the individual and Medicare market dental is just not the same.

Answer: It's difficult to answer why Medicare has so many coverage gaps, and also to know which gaps you're referring to that would be important for you. There are plans that help fill in the gaps, i.e. Medicare Supplement plans were designed for this purpose. There are a variety of plan options, premiums will vary based on the plans so you get to choose how much or how little you want gap coverage.

Answer: Medicare appeals can vary in time so there is no set answer and it may also depend on whether you are trying to appeal with Original Medicare or whether you are trying to appeal a decision with an insurance carrier. I would need more information.

Answer: The cost may or may not be reasonable according to you. You'll want to choose a plan that covers it vs one that doesn't. The Inflation Reduction Act has placed a limit on Part D plans that caps out of pocket medication costs to $2,000 in the year 2025; and $2,100 in 2026 as long as the medication is in the plan's formulary so that is the most your friend will pay in the calendar year.

Answer: Your friend likely opted for a lens not covered by Medicare which may have been a more advanced lens. Ophthalmologists give people options for their lens choice and that should have been discussed.

Answer: Medicare sets the deductible and in many years it does change, that amount is determined by CMS, the Center for Medicare & Medicaid Services. You will typically see an increase in the deductible for Part A, Part B, and Part D of Medicare.

Answer: The 2025 Medicare Part D out-of-pocket cap limits medication costs on a plan's formulary to $2,000. For the year 2026 the cap is $2,100. Once someone reaches that cap, their medications (on formulary) for the rest of the plan year will be $0 copay or $0 coinsurance. Medications not on the formulary do not apply to this cap.

Answer: If you are healthy, you can apply for a different Medicare Supplement Plan (aka Medigap plan) at any time. These plans generally require medical underwriting so if you can pass underwriting, then yes, but if you cannot, then no. Some states have a Birthday Rule which allows people who would not otherwise qualify to change plans based on medical conditions/health history, where they can have guarantee issue into another Medicare Supplement plan, but this rule is in very few states.

Answer: We dont' say free. There are Medicare Advantage plans with a $0 monthly premium. There are various copays and coinsurance in the plans. You'll want to review all your plan options and review the plan Summary of Benefits.

Answer: You can change your Medicare Advantage Plan during Medicare's Open Enrollment Period (October 15 - December 7th) for an effective date of January 1st. There is also a Medicare Advantage Open Enrollment Period January - March to make a plan change in the event you weren't happy with the choice you made during Open Enrollment.

There are also other instances called Special Enrollment Periods in which you can change, and there are multiple, but one is that you moved out of the plan's service area.

Answer: Medicare, which I assume you mean Original Medicare provided by the government, cannot drop you for health reasons. If you don't pay your Part B premium they can drop you from Part B of Medicare, but that is for non-payment, and then you'd have to wait until the general Open Enrollment (Jan - Mar) to enroll with an effective date of July, and you may be assessed lifetime penalties.

You also cannot be dropped from a Medicare Advantage plan for health reasons. If you have a Medicare Supplement plan and you lied about your health history you can be dropped/ terminated due to lying as they would not have had accurate information to underwrite your application.

Answer: I'm not sure what you mean by "legitimate". They do need to be licensed and contracted with insurance carriers in order to sell Medicare plans. That being said, you can go to your state's website to see the active status of an agent's license. Their license number is supposed to be on any communications they have with you. You won't really know if they're contracted with a specific company though, but they cannot sell without being so. The annual certification process can be extensive depending on how many companies they contract with, and Medicare penalties for a variety of things so it is highly doubtful anyone who is not a Medicare agent would claim to be because it just wouldn't be worth it. You don't pay the agent, the insurance company does so there is no incentive for a fraudulent person to make this type of claim.

Answer: Original Medicare doesn't cover hearing aids, but some Medicare Advantage plans do, which may or may not be in your area. You'll need to review plan benefits of the plans that are in your area or have an agent help you. If there are no Medicare Advantage plans in your area that offer hearing aids, there are some companies that offer dental insurance plans where vision and hearing is a rider and hearing aids have coverage under those riders. You can find an agent in your area to help you.

Answer: You should work with an agent and they can conduct a prescription analysis for you. Various insulin medications have reduced in cost due to the Inflation Reduction Act so I can't answer your question outright. I will also say that many Medicare Advantage plans cover many medications a lot better than stand-alone drug plans do - not always, but often. You can also go to Medicare.gov to do the analysis yourself.

Answer: I can't say whether you made a mistake, but I can see how that can happen, depending on the plan you chose and the services you received that have a high copay. It is important to review plan Summary of Benefits and pay attention to their Annual Notice of Change that is sent just before Open Enrollment. Review your plan options, and determin what's most important to you in a plan. Some low premium plans are very generous in their benefits so it really depends. You should work with an agent to help you review plan options available in your area.

Answer: If you only have Original Medicare, it will cover approximately 80% of medical expenses, but there are gaps where you have deductibles for Part A and Part B of Medicare, and it does not cover Part D prescription drug coverage. There is also no out-of-pocket maximum with Original Medicare so the sky is the limit for what you may be responsible for. If you don't enroll in a Part D plan, at whatever time you do, or enroll in a plan that includes it, you will have lifetime penalties that are accessed of 1% per month for every month you did not enroll, and you're limited in terms of when you can enroll. I don't recommend it.

Answer: I have a Medicare 101 discussion with them in how Original Medicare works, and their two primary paths which are either choosing a Medicare Supplement (also known as a Medigap policy) with a stand-alone Part D plan; or choosing a Medicare Advantage plan with Part D embedded works. Those choosing a Medicare Advantage plan should have Part D included unless they get Part D from the VA or similar, otherwise there are a variety of issues too complicated to go into in this response.

We talk about how their healthcare experience, are they used to PPO-style care or HMO-style care and how their past experience of what they are used to may impact how they want to receive care - it's part of the "what's most important to you" conversation for healthcare.

Answer: No, absolutely not as a general rule is that a wise idea. There is much more to choosing a plan than simply the cheapest plan available. Sometimes its a fit, and sometimes its not. And by cheapest plan, they likely mean a Medicare Advantage plan, which can range in benefits, premium, coverage, doctor networks etc.

It depends on what's important to you. If having freedom and flexibility of care where you're not constricted to a network, that's not going to be the cheapest plan. If you want low cost along the way but as healthcare needs arise paying various copays, that's another type of plan.

When I'm reviewing plans for clients I conduct a prescription analysis to see how various plans cover their medications as every plan covers medications differently. I check various networks to see what networks their doctors are in, if any, and we have that discussion in how important their doctors are, especially if they're not in any networks and those doctors are important to them. What hospitals are in network etc. We go over how Medicare Supplement plans are different than Medicare Advantage plans, and how Part D comes into play with both, and if there are PPO Medicare Advantage plans in the area how those compare to HMO plans in the area.

As you see, there are many considerations to choosing a Medicare plan.

Answer: It depends on how long ago you took out your policy, if you aged in for eligibility i.e. just turned 65, or other factors. If you just took out your policy and you didn't have a guarantee issue basis, such as turning age 65, there is a medical underwriting question you would have had to answer which is about upcoming surgeries. If you were not honest with this answer, they can terminate your policy. You question does not provide enough information to answer so I suggest you call your agent/broker, or the plan to get an answer based on your scenario and all that is involved.

Answer: There are some people who like to do everything themselves, but depending on your situation, you may not realize there are different rules for different parts of Medicare with different timing, and there are situations that if you don't know the rules, could land you in trouble with lifetime penalties.

Not all Medicare agents are the same though so as you look for an agent, look for one who will educate you on different types of Medicare plans, some will steer you in one direction or another without asking what's important to you.

A good agent will guide you through the process, help advocate for you when issues arise, and you have a go-to person who can answer questions about your plan vs you calling 1-800 transfer me around multiple times, put me on hold forever, then drop the call where I have to start all over again - believe me, it happens to us as agents too and if we can help alleviate that for you, then so much the better. And with companies replacing people with AI and calling the government for answers, that in and of itself is reason enough.

Plus there is no difference in what you are paying in premium for whatever plan you decide to go with as agents get paid by the insurance company you enroll in. You do not pay an extra fee to work with an agent.

That's just a few high-level points.

Answer: Paying into Social Security is different than paying into Medicare. If you do not have 40 quarters (10 years) of working history in the U.S. where you and your employer (or if you're self-employed you would also have the employer portion) where you paid into Medicare, you can obtain Medicare at age 65 but you will have to pay for Part A whereas if you paid into the system during your working career Part A will not have a cost for you once you stop working. Contributions towards Part A are paid during one's entire working career in the US typically and stop when they retire.

If you've never paid into the system, you will be at the highest Part A premium. This amount used to be posted on Medicare's website but they took it down. If you create an account on Medicare.gov you should be able to obtain this information as the premiums can change annually and the 2026 numbers should be posted anytime within the next few weeks.

Part B of Medicare generally isn't turned on until one reaches age 65, nothing is paid into Part B as is the case with Part A. Medicare Part B does have a monthly premium.

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