Zachary Montgomery, Medicare Insurance Agent

Answer: Medicare advantage plans are not free and never have been. It is absolutely deceptive marketing in my opinion. Enrollment in Medicare Advantage requires enrollment in parts A and B. Most people are required to by $0/month for A and $202.90 for part B. It is sometimes more for either of those parts. Medicare advantage (or part C) replaces parts A and B, but still requires those premiums before paid. Part C plans may require additional premiums, or they may require less. However, part C always requires a premium. In the event that your part B premium is $0/mo, your part B premium is still actually $202.90 but is being paid by a Medicare savings plan or Medicaid. When comparing original Medicare, Medicare advantage, and Medicare supplements, it is important to compare your total monthly premiums, total annual exposure, and the actual benefits provided.

Answer: Because Medicare is such a robust coverage model with guaranteed issue options regardless of health, it is a very expensive healthcare model. To mitigate this, individuals are required to enroll within certain periods to collect premiums before it becomes necessary for those beneficiaries to use their benefits. To further mitigate individuals that do not enroll within those time periods, fees or penalties are levied to offset their missed premiums. While Medicare is not mandated, many other forms of health insurance is illegal after Medicare eligibility. It is important to meet with your agent to understand when you should or should not enroll in Medicare and how to avoid penalties correctly.

Answer: Medicare covers medically necessary surgeries and procedures following the part b deductible and coinsurance costs. If a joint replacement is considered medically necessary, it is covered. In my experience in my practice, if pain or lack of functionality has gotten to the point a doctor recommends replacement, Medicare will cover.

Answer: Medicare Advantage plans are required to cover the annual wellness visits as part of their contract with Medicare.

Answer: In years past, prescription drug costs had no maximum out of pocket. Beneficiaries were responsible for deductibles, initial coverage copays or coinsurance depending on the drug formulary, a secondary copay or coinsurance amount after a certain threshold (called the gap or donut hole) and a third copay or coinsurance amount after a final catastrophic threshold. Now, plans have a deductible (for which some medications are exempt and move straight to the coinsurance or copay phase) and then coinsurance or copay phase. There is also now a maximum out of pocket for covered medications which is $2100 in 2026. It is important that you verify your drugs are in the formulary in order for this maximum to correctly apply to your drug spending. Anecdotally, in my business, has also meant that generally drug costs have increased on plans. Specifically for part D monthly premiums. Medicare Advantage plans seem to have absorbed this cost by providing reduced secondary benefits but sometimes by changing formularies and cost sharing.

Answer: Medicare Advantage plans vary from plan to plan. PFFS plans will work with any provider that accepts the plan’s terms and conditions. PPOs cover providers that are out of network but usually at higher costs. HMOs only cover providers that are in network except for certain situations. You will have to balance the financial cost of using providers out of network against the general cost of changing providers.

Answer: Part B covers a lot of preventative screenings such that they are not subject to the deductible or coinsurance payments. If the mammogram is a screening, it meets this requirement. If it is diagnostic, the service is covered but subject to the deductible and coinsurance payments. The Medicare app “What’s Covered” is a great resource to quickly identify services that are covered and how deductibles and coinsurance apply.

Answer: Preconceptions about Medicare often “poison the well”. For instance, many times clients will be expecting their Medicare rights and options to be the same as one or more of their peers, but those options only exist for their peers because they meet certain prerequisites such as dual enrollment with the state Medicaid or Medicare Savings Programs, chronic illnesses, or being in a service area for which a given plan is not located. Unfortunately, some Medicare beneficiaries believe that plans and options are being withheld from them and not that my hands are tied as the agent. Fortunately, this is not common, and most beneficiaries will call me back when they do follow up research to verify.

Answer: Yes, loss of credible coverage allows for guaranteed enrollment into the comparable parts of Medicare for which you are losing the credible coverage. In most scenarios, loss of group coverage will create a guaranteed issue window for Medigap. It is a short window compared to other enrollment opportunities, so meet with your agent as soon as you are aware that you are losing the coverage.

Answer: You may be denied coverage under traditional Medicare supplement plans. These plans generally offer more robust coverage options and therefore will usually have health requirements that must be met before acceptance. There are exceptions, however. Some exceptions will be unique to your state of residence or be niche scenarios, but generally the following situations will allow you to select a Medicare supplement for guaranteed acceptance: new or reinstated part b enrollment, turning 65, Medicare advantage 12 month trial period, or involuntary disenrollment from your existing plan. For more niche scenarios, contact your agent.

Answer: Medicare can cover skilled nursing care if conditions are met. This is probably better referred to as rehab coverage. It does not cover assistance with activities of daily living such as nursing homes or assisted living commonly referred to as Long Term Care. Skilled nursing care may occur at the same time as Long Term Care, but only the skilled nursing may be a covered expense. There are other options for handling the expense of Long Term Care or assisted living. Discussions around these options should generally be held with your financial advisor or your health insurance agent - particularly an agent knowledgeable about state partnership plans - to help determine which path works for you and your family. Finally, it is important that these conversations happen while you are still healthy and not when you need care.

Answer: Medicare will often be unique for each individual family, both when it comes to rights and options as well as suitability. It also has some rules and constraints that can be convoluted or counterintuitive. A quality agent will have been exposed to lots of these unique situations and be up to date on changes in the regulations as well as trends in the overall Medicare landscape to help their clients avoid pitfalls, penalties, and higher costs. These rules can change after you have enrolled in Medicare. These changes may or may not affect you, but your agent will be aware of them and usually be ready to help you respond - often before you know there’s a problem.