Medicare Questions & Answers: Advice for Seniors
Advice for Seniors Q&A
Showing 107 questions
Are Medicare Advantage plans really "free," or is that just clever marketing?
The concept of "free" Medicare Advantage plans can be misleading. While some Medicare Advantage plans advertise $0 monthly premiums, it's crucial to understand that this doesn't mean you won't have any healthcare costs. Here's a breakdown:* $0 Premium Doesn't Mean $0 Cost:
A $0 premium means you don't pay a monthly fee to the private insurance company offering the Medicare Advantage plan. However, you'll still likely have other out-of-pocket costs, such as:
* Co-payments: Fixed amounts you pay for specific services (e.g., doctor's visits, prescriptions).
* Coinsurance: A percentage of the cost you pay for services.
* Deductibles: The amount you pay before your plan starts covering costs.
What is the biggest mistake seniors make when enrolling in Medicare?
It sounds cliché coming from me, but the biggest mistake seniors make is not having an independent agent acting on their behalf. When calling into insurance companies for help, their sole job is to sell you their product, whether it's the best option for you or not. You want someone who has a financial incentive to assist you in finding the right type of coverage by going over all your options and not leaving anything to chance. Imagine a doctor that only wrote you prescriptions from one pharmaceutical company; you'd have questions about their motives just as I would too.
What are the reasons why I should work with a Medicare agent?
The only reason you should work with a medicare agent is because of the quality of understanding you get from quality agent. A true agents purpose is to do right by the consumer. A true agent should be able to communicate the medicare Information clearly, communicate why its important and how it affects you annually. They should be able to not only be responsive but cater to finding a plan where you dont have to change your Dr's or hospitals to use the plan. They will provide you with an annual review to make sure you are always in the best place medically. A quality agent is strong enough to put commission aside to help there consumer.
What benefits are there to working with a Medicare Agent near me vs remote/virtual?
There are many benefits to working face to face and virtually with a Medicare Agent.A local can give a more personal approach. Local agents understand the plans available in your specific area which includes doctors, hospitals, and pharmacies.
I personally find, that local agents are extremely more helpful and responsive for follow up issues, claim help, and have a personal knowledge of your needs based on the relationship that is built. A local agent also understands state specific Medicaid programs and Medicare Supplement and Medicare Advantage options in your state, since these benefits vary for each state.
In recent days, working virtually has become a favorite with my clients. Having the flexibility to meet with my clients without travel time is a plus because it gives me the option to work longer hours and across state lines in different time zones. If convenience, flexibility, and you are used to working with computers is appealing to you, working virtually may be the right choice. Everything that is done in person can be done virtually as well.
If you are looking for help, please contact me. I would be happy to review and answer questions.
What's one piece of advice you wish every senior knew before picking a Medicare plan?
I wish every senior knew that the 'best' Medicare plan isn’t the same for everyone...it’s the one that fits your specific needs and budget.Too many people pick a plan based on what their neighbor has or just go with the cheapest option, only to find out later that their doctor isn’t covered or their medications cost way more than expected.
Take the time to compare your options, ask questions, and make sure you’re choosing a plan that actually works for you. And if you're feeling overwhelmed, talk to an expert, because guessing your way through Medicare can be an expensive mistake!
What's the most important question I should be asking about Medicare that I probably haven't thought of yet?
The question you aren't asking might just be what options give me most control of my healthcare? The opposite question is important as well, What might limit my healthcare? With Advantage plans you have to stay in-network for your care and often there are prior authorization hoops to jump through.With Medicare supplements there are fewer prior authorizations and when there is one they are generally just looking for Fraud, Waste, and Abuse. What they are not looking for are ways to protect their profits. They aren't looking for how they can squeeze more money out of the system to pay their CEO or have more money for their marketing budget.
Yes, there are times when an Advantage Plan is the right fit. It does depend on your budget and the amount of control you have really depends on the company you go with. In general though I think you retain more control of your healthcare with traditional Medicare and a supplement.
What is one of the the most common misconceptions people have about Medicare?
One of the most common misconceptions about Medicare is that it covers all healthcare costs for seniors. Turns out, Medicare doesn't cover every single healthcare expense. Additionally, many assume it includes long-term care (like nursing homes) or dental, vision, and hearing services, but these items are not covered under original Medicare. People often learn this the hard way when they realize they need supplemental insurance like Medigap, Medicare Advantage, and other tertiary coverage options to fill those gaps. It’s a rude awakening for those who think Medicare = free healthcare, hence the need to fully understand your options to make the best decision for yourself.
What's the trade-off between a Medicare Advantage PPO and HMO when it comes to flexibility?
An HMO limits your services to a closed network of physicians and caregivers. HMOs require members to choose one of their in-network primary care physicians to manage your healthcare, and require a referral approval to use other in-network services. HMOs generally do not allow any out-of-network services unless it's an emergency.PPOs are more flexible with their network of services and do not necessarily require a primary caregiver. You can use services outside of their network of treatment services, and you will still be covered. However, PPOs generally have higher prices, deductibles, copays, and coinsurance when you use services outside of their network.
What's one Medicare decision that too many people regret later?
Selection of an MAPD when they could have enrolled in supplemental plan and separate PDP during their initial IEP. Too many (in my opinion) are led to the MAPD side without having the client sign-off on an affidavit saying they have in fact received a thorough discussion of the pro's and con's of both sides of the Medicare decision fence.
If a senior is turning 65 but still working, should they enroll in Medicare or delay it?
If you have employer-based health insurance through your or a spouse's current employment, where there are more than 20 employees, and you're happy with the costs, such as monthly deductions/premiums and coverage, like potential out-of-pocket costs, you can delay Medicare enrollment without accruing penalties. If this is you, it's best to schedule a quick call so we can discuss your situation. Chad
What's the most frustrating misconception you have to clear up with clients about Medicare every year?
One of the most frustrating misconceptions I often have to clear up is the belief that Medicare is completely free and covers everything. Many clients are surprised to learn that Medicare has premiums, deductibles, copays, and that it doesn’t cover everything like dental, vision, hearing, or long-term care. Medicare plans are not a one size fits all and when i meet with my clients, i do a Client Needs Assessment to find the right plan for YOU.
How can I make sure I'm not overpaying for my Medicare plan, and are there any tools or resources you recommend?
Find a local trusted insurance broker whom can answer your questions and explain things in easy to understand terms. If you are more of a do-it-yourself person I would highly encourage you to read through the Medicare and you book and also use the tools available on medicare.gov website
Do Medicare Advantage plans really save seniors money in the long run? Why or why not?
Medicare Advantage plans can potentially save seniors money in the long run, but the impact varies by individual circumstances. They often have lower premiums and may include additional benefits not covered by Original Medicare, such as vision and dental care. However, these plans might have higher out-of-pocket costs for certain services and often require members to use a specific network of providers. It’s important for you to evaluate their healthcare needs and compare costs before choosing a plan.
How do discount cards and resources affect my Medicare Prescription Drug plan?
Normally Discount Cards (Good RX and others) may discount your Prescription cost at certain pharmacies. This may be a way to save on Prescriptions when there is a higher copay. These companies may gather your information and market Medicare plans.There are State Resources available to help with Prescription costs. There are many generic medications that could be $0 copay in Medicare Advantage or Standalone RX plan. Brand Medications can have copays.
State programs have an application and can take up to 2 weeks to 4 months to be approved. These programs have income guidelines to qualify. Most do not consider assets.
NJ PAAD
PA PACE
If you have questions on the state resources, please contact me for more information.
If you had to pick just one, what's the worst Medicare-related decision someone can make?
In my professional opinion, the worst Medicare-related decision is choosing a plan without assessing one’s individual circumstances and relying instead on unsolicited advice from others. I frequently encounter clients who select coverage based on someone else’s experience, only to discover it doesn’t align with their specific healthcare or financial needs. This misstep often leads to unnecessary complications or expenses that a tailored evaluation could prevent.
My mom is considering switching to a Medicare Advantage plan because her friends say it's better. She's scared of losing her current doctors. How can we check?
Having good, reliable doctors that you trust is really important. When looking into an Advantage plan, the first thing to consider is if a doctor is "in network". When a doctor is "in network" it means that the plan will cover those visits. If a doctor is "out of network" you will not be covered by the plan. When I meet with a person, I have a system that will narrow down plans that each doctor is covered by so that we can ensure the best coverage and benefits which is unique to each individual.
How does life insurance contribute to financial planning?
Life insurance can be very crucial to financial planning. Life insurance is something that should be in investigated sooner rather than later. A good benefit Rich policy May offset Some costs in the case of a passing that incurred medical debt.
I'm a low-income senior who can't afford my prescription drugs even with Medicare Part D. What specific assistance programs should I apply for?
As a low-income senior, it can be challenging to afford prescription drugs, even with Medicare Part D. However, various assistance programs are available to help alleviate this burden. This document provides a comprehensive guide to specific assistance programs you can apply for to receive the help you need.1. Extra Help from Medicare
To qualify for Extra Help, you must:
• Be enrolled in Medicare Part D
• Have an income below 150% of the federal poverty level
• Have limited financial resources
How to Apply
You can apply for Extra Help through the Social Security Administration (SSA) website, by calling SSA, or by visiting your local SSA office.
2. State Pharmaceutical Assistance Programs (SPAPs)
Eligibility requirements for SPAPs differ depending on the state, but they generally include:
• Residency in the state
• Enrollment in Medicare Part D
• Meeting specific income and resource limits
How to Apply
To find out if your state has a SPAP and how to apply, visit the Medicare website or contact your state's Department of Health Services. - https://www.medicare.gov/basics/costs/help/drug-costs
3. Pharmaceutical Company Patient Assistance Programs (PAPs)
Each pharmaceutical company has its own eligibility requirements, but they generally include:
• Having no insurance coverage or limited coverage for the medication
• Meeting specific income limits
4. Medicaid is a joint federal and state program that helps with medical costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including prescription drugs.
Eligibility Criteria
Eligibility for Medicaid varies by state, but typically includes:
• Having a low income
• Meeting specific resource limits
How to Apply
To apply for Medicaid, contact your state’s Medicaid office or visit their website.
I've heard that once you're on Medicare, you might not need life insurance as much. Is that true?
This is not true. Life Insurance is always a good choice. Many retirees who leave jobs and retire find themselves without Life Insurance. There are many options for Life Insurance and Retirement planning even at 65 and older. I would recommend asking your Medicare broker for resources or a Retirement plan review.Medicare does NOT cover funeral expenses.
I don't understand how my friend pays nothing for their plan and I pay over $200-are these plans just totally random by ZIP code?
The plans are not random. If your friend pays nothing for his Medicare plan, this is highly likely to be a Medicare Advantage plan featuring deductibles, copays and coinsurance depending on the plan. Most advantage plans feature a $ 0-dollar copay to see your primary doctor but will have a $30-to-$ 50 dollar copay to see a specialist and there will be additional costs depending on what's going on. Now if you are paying over $ 200 for your plan, you may have a very high-benefit Advantage plan but it is more likely that you have a Medicare supplement plan and this is a different animal. Medicare supplement plan F pays after Medicare leaving you with no medical bills for health services for Medicare-approved services (or no bills after a 2025 $ 256 outpatient deductible if you have a supplement Plan G). Talk to your independent insurance agent about all this otherwise get your license and help me explain this stuff!
I'm confused about when I can change my Medicare plan. Can you clarify the different enrollment periods for me?
Medicare Advantage Plans (Part C) can be changed during the Annual Enrollment Period - October 15th to December 7th, or during the Open Enrollment Period - January 1st to March 31st. There are also some Special Election Periods that can be used, such as:* You change where you live
* You lose your current coverage
* You have a chance to get other coverage
* Your plan changes its contract with Medicare
* Other special situations
Medicare Supplement plans can be changed at any time throughout the year if you qualify medically. Some states even have guaranteed issue periods such as 60 days following your birthday, loss of creditable coverage through employer or another plan, or if the plan exits the market.
Prescription Drug Plans (Part D) can only be changed during the Annual Enrollment Period - October 15th to December 7th, unless there is a Special Election Period that would allow you to change.
Why do some seniors end up paying lifelong penalties for Medicare Part B or Part D?
Lack of appropriate retirement planning education. One of the foundations I have built my business on is education. Medicare 101 seminars can be really useful to people to learn how to avoid these penalties.It is important to know that unless you have what is known as Creditable Coverage, delaying Part B and or Part D can carry lifelong penalties. Each situation is unique so it’s important to consult with a professional to understand if you have Creditable Coverage or not and have a plan in place, months before you turn 65. Sorting out your Medicare coverage is best done up to 3 months before you turn 65.
What additional coverage options are available for international travelers?
Medicare Supplement plans (Medigap) C, D, F, G, M, and N may offer coverage for services outside of the U.S. with up to $50,000 of lifetime coverage. Some Medicare Advantage plans may also provide some coverage, and travelers should check with their specific plan for details. Additionally, international travel plans can provide emergency medical evacuation, return of mortal remains, support for lost passports or luggage, trip cancellation protection, and even kidnap and ransom coverage for high-risk destinations.
I'm turning 65 next month and the amount of Medicare mail I'm getting is overwhelming. How do I sort through all this?
My advice to people is to put all of it aside. If you try and read all of it your head will explode. Find an Independent Medicare Broker and use them as your Adviser, their services are free and if you choose one that only does Medicare, you'll be getting an expert
I need a hearing aid but I've heard Medicare doesn't cover them. Is there any way around this?
Original Medicare does not cover hearing aids. However, most Medicare Advantage plans cover hearing aids and offer them at a discount or copay through their approved Vendor. Check with your local Broker if you are enrolled in a Medicare Advantage Plan.My neighbor says I'm crazy for paying for a Medigap plan when Medicare Advantage is "free." What should I tell him?
Medicare Advantage Plans are not FREE. They may have a $0 premium. However, you must continue to pay your Medicare part B premium to qualify for a Medicare Advantage Plan.
How do you approach educating clients who are new to Medicare versus those who are considering switching plans?
For my Turning 65 clients, I start with the ABC's of Medicare so that they understand the basics of Original Medicare. I want them to understand the differences between Original Medicare, Medicare Supplements, and Medicare Advantage plans so they are confident in making good decisions. Specifically, what gaps they want to supplement with a Medicare Supplement or what benefits they want to replace with a Medicare Advantage Plan. I also spend a good bit of time educating them on what they need to know if they plan to work past 65. The average retirement age is now well beyond 66, so comparing employer group health plan benefits to Medicare is a critical step in the decision making process. I want to ensure seniors set themselves up for success down the road, which includes the best coverage for the best price- and to avoid potential late penalties.For my clients that are considering switching plans, because I am a broker that represents all major carriers, I routinely monitor any changes in their health/financial situation against the changes that the carriers are making. Each year carriers make changes, and each year I ensure all my clients have a complete review of their current plan, so they can compare and make changes if needed- leaving them with the confidence that they know they are in the best possible plan for them.
Can I use a health savings account (HSA) to pay Medicare premiums after I retire?
Yes, absolutely. In addition to paying Medicare Part B, Part D, and Medicare Advantage (Part C) premiums, you can also use your HSA funds tax-free to cover out-of-pocket costs like copays, coinsurance, and deductibles for those plans. That includes copays at the pharmacy under Part D or doctor visit copays under a Medicare Advantage plan. HSA funds can also be used for dental, vision, and hearing expenses—even if Medicare doesn't cover them. Just remember, once you're enrolled in any part of Medicare, you can no longer contribute to your HSA, but you can continue to spend what you've already saved. It's a great preplanning tool for managing healthcare costs in retirement with tax advantages.
What do I do if I cannot afford my Medicare premiums?
You can inquire on a reduction to your Medicare Part B premium by calling Medicare at 1800MEDICARE. When you call Medicare please note the date of the call & the Medicare representative's name. If you call Medicare back, you will most likely not get the same representative on that call.You can also apply for Medicaid in your State of residence. Please call your State's Medicaid Office. Thank you.
Every year I stress over picking a plan and still end up surprised by the bills. Is there any way to just get peace of mind with Medicare?
Change from medicare advantage to Medigap. You will pay a monthly premium but never get a bill. You can keep the plan forever and have peace of mind knowing your exact cost upfrontWhat should I look for in a Medicare plan if I travel frequently both domestically and internationally?
If you travel within the US - reviewing plan choices that offer a Nationwide network is key.If you travel internationally - Travel insurance is available based on your dates of travel.
Review with a local Medicare Broker, contact me for specific questions.
Why do some clients ignore your advice and end up in bad Medicare plans-what makes them resistant?
Great question.. It happens occasionally.. I represent all the major plans and focus on their doctors and prescriptions not the shiny objects that some plans offer. So I don't run into it very often.. When I do it usually has to do with an added benefit.. Example: I recommend a plan that fully covers all their docs and prescriptions. Say it has a $1500 dental benifits.. They see a plan with a $3000 benifits and they decide to go with that.. However that plan doesn't have the same coverage for doctors rxs. It's not that they got bad plan, they just end up making a decision based on that shiny object that reduced the real important coverages.
What role do annuities play in retirement planning?
Imagine having a reliable stream of income flowing in during your retirement. That's the magic of annuities! You can purchase an annuity with a lump sum or through regular payments, and it can provide a guaranteed income stream throughout your retirement. Some annuities even offer lifetime income, meaning you'll receive regular payments no matter how long you live. This can be a game-changer for supplementing Social Security and other retirement income, allowing you to live comfortably and worry-free.How can I select the right healthcare company and representative to work with?
A good representative Will usually be very easy to spot ( Medicare agents hub ). If you End up finding someone that you trust then the carrier that you go with becomes Not as important. I have several clients and I can speak from experience in saying that putting them all on the same“good” plan Is not the right thing to do. Every individual is different, And a good representative should match up your needs with a plan that’s best for you.
What's a red flag in a phone call that it might be a Medicare scam targeting my personal info?
If someone calls a beneficiary and wants to speak to him/her about Medicare they should ask them for their name, phone number and agency they work with and then tell them you will report them to the Centers of Medicare and Medicaid Services. Medicare beneficiaries cannot be called by anyone unless they have previously given that person their permission to be contacted.
What's the biggest mistake seniors make when choosing a Medicare Part D plan?
The 2 biggest mistakes that seniors make when choosing a Medicare Part D plan are:1. Not verifying the listed prescription or tier level on the plan's formulary.
2. Enrolling in a plan where the monthly premium is excessive in comparison to the monthly cost of the prescriptions. Example: Paying a $103/month for plan for when you're only taking generic prescriptions.
Can Medicare drop me for health reasons?
Medicare can NOT drop you because of health reasons. If you have a Medicare supplemental plan and drop the plan because you want to change to a Medicare Advantage and you are on the Medicare Advantage for more than 12 months you will be asked health questions to go back to a Medicare Supplemental plan and some people can not qualify. Or if you missed a monthly premium and have a lapse of coverage, you may have to answer health questions to get back and you may not qualify.
I'm interested in nutrition counseling to help manage my diabetes. Will Medicare cover this as preventive care?
Medicare part B does cover with a referral from a doctor to a regestiered dietitan or specialist. But it all starts with your doctor.
So my friend told me I should just go with the cheapest Medicare plan. That sounds too simple - what am I missing?
The cheapest plan may or may not be your best choice. Depending on your personal needs and budget. It’s always best to look at and compare all your options and be sure you understand the differences in each plan. There is no one size fits all and it’s much better to discuss your choices with a licensed agent rather than depending on options of anyone that isn’t trained and certified to explain all options and not just select plans.
What are the red flags I should look for when interviewing agents? I want to make sure I'm not just getting sold to but genuinely advised.
I would find out how long they have been selling Med supps and Medicare Advantages and why they like this market. I would also have them explain the difference between the two. Can they do it in a way that you understand stand it. I would also like to know how many companies they represent. If just one then that's all you will get told about. They should also be asking you questions about your doctor's, like their names. Plus the drugs you are taking and what your specific health situation is. They should be asking questions to find out what your enrollment situation is. The health situation will tell them what you may or may not qualify for. By getting these questions asked hopefully it will give you a better feel of the agent and if they can assist you or not.Cleo Martin
What's the cheapest way to get Medicare coverage if I only need basic hospital care?
I would never advise someone to ONLY enroll in Part A (Hospital)If you skip Part B (outpatient care) to avoid its monthly premium - here’s the catch: if you delay Part B and later decide you need it, YOU'LL FACE A LATE ENROLLMENT PENALTY —10% added to the premium for each year you could’ve enrolled but didn’t—unless you have other creditable coverage (like an employer plan). Also, Part A alone won’t cover doctor visits, labs, or outpatient procedures, so if “basic hospital care” might stretch beyond inpatient stays, you’d be paying those extras fully out-of-pocket. For pure cost minimization with a hospital-only focus, Part A solo is your leanest option—just be sure your needs won’t creep into Part B territory later.
What's one hidden Medicare expense that people don't think about until it's too late?
Skilled Nursing Facility Costs. Days 1-20, Medicare pays 100%. Days 21-100, the member pays a daily co-pay. After 100 days, Medicare no longer covers expenses.
I'm getting conflicting information about whether Medicare covers my specific medication. How can I get a definitive answer?
There are 2 ways. You can work with an agent. He can look up all your drugs. He can look at each companies formulary. The second option is to look it up on the Medicare site
I'm on Medicare but recently declared bankruptcy due to medical bills. How will this affect my coverage and options going forward?
I’m sorry to hear that. And good luck.Medicare itself has no credit rating or change in coverage due to BK. But as long as you continue to to make your Part B payments your Medicare will continue to on.
My suggestion is to try to find at least a High Deductible Supplement plan that allows you to keep your Doctor choices and limit the amount of responsibility that can come back to you. If you hadn’t accepted a Medicare Advantage Plan, do not worsen your situation financially with a plan that will control you and your health moving forward.
You can work through Bankruptcy. You can’t work through not allowing yourself the control and freedom that you would then give up on your health by taking an Advantage plan.
How do Medicare Savings Programs help with Medicare costs?
Medicare Savings Programs (MSP) can help people with limited income cover their Medicare premiums, deductibles and other costs like co-insurance. This is also known as a Medicare Buy-In program.Eligibility can be vary by state. Extra help with Medicare Part D drug costs can by applied for simultaneously with the MSP. Income and resources can also vary by state, however most states use income and resource limits based on the Federal Poverty Level (FPL).
Types of MSPs include:
Qualified Medicare Beneficiary (QMB) which helps pay for Part A and B premiums, and covers cost- sharing for Medicare-covered services.
Specified Low-Income Medicare Beneficiary (SLMB) which helps pay for Part B premiums.
Qualified Individual (QI) which helps pay for Part B premiums.
Qualified Disabled Working Individual (QDWI) which helps part Part A premiums for individuals under age 65 who a disabled and have returned to work recently.
You can apply through your State Medical Assistance office (Medicaid).
I went to a free Medicare seminar and it felt like a timeshare pitch. Are any of those events actually helpful?
Though those seminars can be somewhat helpful, your best choice is a one-on-one visit with an independent agent/broker who will take your personal information into account and be specific toward your health issues, your family history and naturally, your pocketbook. With a seminar, it's a numbers game while a visit to your home or at a neutral site is more beneficial.I got a call from a "Medicare agent" promising me free groceries and I almost fell for it. Why is this kind of marketing allowed?
It’s unfortunate but there are a few loopholes in Medicare marketing guidelines that allow agents to discuss benefits associated with “DSNP’s” (Dual Special needs plans) on cold calls. These types of plans require that you have both Medicare and Medicaid, if you have both of these then there may be a DSNP plan available in your area that includes a”healthy food and produce” benefit that gives you a monthly allowance towards OTC items and groceries. Unfortunately I think a commonly used tactic is the “bait and switch”. Agents/brokers have to be a little more transparent if you were to physically meet them and go over your plan options. Be a good practice To ask these individuals “how are these benefits available to me” or simply just hang up. This sure isn’t a way to conduct good business but some brokers do engage in this.
How does moving to a new state affect my Medicare enrollment timeline?
When you move out of a service area, whether from one county to another, or a different state, you must change plans if you have a Medicare Advantage (MA) or Prescription drug plan (PDP). The ability to change plans after a move falls under a Special Enrollment Period (SEP).If you don't notify your plan before you move, you have the month you move and 2 months after (3 months total) to change plans. If you notify your plan before you move, you have the month before, the month of, and 2 months after (4 months total) to make a change.
Plans vary greatly by service area, so don't be surprised if you have different benefits, including maximum out-of-pocket, deductibles, co-pays, and co-insurance. Extra benefits may also differ from area to area.
Be advised that some counties with low populations don't have MA plans, so adding a supplement and a PDP may be your only option. Medicare Supplement SEPs are similar but exclude the month before a move. You can join a Medicare Supplement plan the month you move and up to 2 months after. Guaranteed issue is available ONLY if there is no MA plan available in your new service area.
Sound complicated? Contact me and I'll walk you through it.
How do I know if a Medigap policy is right for me, and what's the best time to buy one?
A Medigap policy is right for you for a number of reasons:1. You are in the younger market like age 65 and that gives you a low premium.
2. You're health is not great, many doc visits, maybe a few chronic conditions requiring on going services.
3. Medigap policies follow Medicare's lead, and Medicare patients are treated everywhere. In other words, Medigap clients don't hear "no" when or if they want to go to a specialist locally or anywhere in the country.
I've heard about IRMAA affecting my Medicare premiums. How can I find out if it applies to me, and how does it work?
IRMAA (Income-Related Monthly Adjustment Amount) affects Medicare Part B and D premiums for those with higher incomes, and it's determined by the Social Security Administration based on your income from two years prior. You'll receive an "Initial Determination" if IRMAA applies to you.What are the signs that it's time for me to switch my Medicare plan, and how often should I review my options?
There's three signs I always tell people it's time to go shopping for other options:1) Cost changes (prescriptions, copays, premiums, etc.)
2) Health changes like new meds or complications
3) Doctor changes
I'll also throw in if your benefits change on your coverage. Those are all reasons I'd want to review my coverage to see if anyone is offering better.
That being said, I will always tell people that a good time to check your coverage is at least once a year. Typically we do that review with our clients anyways.
What's the best way for seniors to protect themselves from Medicare-related scams?
Protect your information as there are many scams out there today, unfortunately. Verify Brokers/Agents licensing on the particular state those agents/brokers are inI've been diagnosed with prediabetes. What preventive services does Medicare cover to help prevent progression to type 2 diabetes?
Preventive care is not done on the bases of your medicare but on the quality of care from your doctor. A good doctor will provide good care and education to prevent progression of illness. Depending on your insurance and dietary needs set by your physiscian, you can utilize benefits like nutrition health as well as gym memberships to support a good healthy habit which are typically included with your coverage.I'm planning a long trip overseas. What happens if I need medical care while I'm away from the US?
No, in most cases, Medicare does not cover medical care received outside the United States However there are some exceptions and some Medicare Supplements may cover some emergency coverage for travel abroad. It’s important to know what your plan offers.My doctor mentioned something about Medicare not covering my procedure. How do I find out for sure before I get stuck with a bill?
Suppose you're under Medicare Part A and Part B with a Medicare supplemental insurance, and the physician sees a need for a diagnosis due to your health circumstances. In that case, the procedure should be covered, less any amounts for Medicare Part B premium or deductibles, and this is based on the type of supplemental plan you have. If you're on Medicare Part A and B with a Medicare Part C - Advantage plan, then your coverage could only be determined with the prior approval procedure through the insurance carrier of your Advantage plan. Most likely, there will be additional deductibles, co-pays, or out-of-network charges under these plans.
So with all these 2025 Medicare changes, should I be switching plans or staying put?
That’s really on an individual basis. If you have a Medicare Supplement, those don’t change from year to year, so the only thing you need to review with your agent is your Prescription Drug Plan.Medicare Advantage plans DO change from year to year. The two questions you should ask your agent:
1) Are there any negative changes to my plan, and
2) Any positive changes, or better options for me?
The one thing you should NOT do is assume that staying in the same Medicare Advantage or Prescription Drug Plan will give you the exact same coverage from one year to the next. They can change - even if you don’t.
I'm confused by all the star ratings for Medicare plans. Do they actually mean anything for the care I'll receive?
Medicare Star Ratings measure the quality of Medicare Advantage and Part D plans.If you have a Medicare Advantage plan, you should know about the star rating on your plan.
Star rating uses a 1 to 5-star scale.
A 5-star rating means excellent performance. The ratings are based on factors like member satisfaction, customer service, and health care quality. Plans with higher stars often offer better care and service. Ratings are updated yearly by Medicare to help beneficiaries compare plans and make informed choices. Choosing a higher-rated plan can improve your overall experience and access to care.
You may also switch to a 5-star plan during a special enrollment period, even outside of the usual enrollment times.
My kids keep telling me to get a Medicare Advantage plan, but my friends say stick with Original Medicare. Who should I listen to?
Original Medicare has deductibles and co-insurance and doesn't include drug coverage-part D (If you don't have a PDP- Prescription Drug Plan-and haven't had one for over 63 days after your initial enrollment period has passed, you'll pay a lifetime penalty when you sign up.) With original Medicare, you can go to any doctor who accepts it.In 2025, part A has a $1,676 deductible. You pay:
Days 1–60: (of each benefit period): $0 after you meet your Part A deductible ($1,676).
Days 61–90: (of each benefit period): $419 each day.
After day 90: (of each benefit period): $838 each day for each lifetime reserve day (up to 60 days over your lifetime).
After you use all of your lifetime reserve days, you pay all costs.
There's a term here, "benefit period". The benefit period lasts for 60 days. If you are out of the hospital for over 60 days, the process starts over, and you pay the deductible again (lifetime reserve days do not start over).
Part B has a $257 deductible, with generally a 20% co-insurance after it's been met. Original Medicare has no maximum out-of-pocket. If you are in the hospital multiple times during the year, the costs can be financially devastating.
Medicare Advantage plans have maximum out-of-pocket limits built into their plans. Depending on where you live, there are both HMOs and PPOs to choose from. HMOs require referrals to see specialists. PPOs are more flexible but costs for out-of-network doctors are higher.
Another option is Medicare Supplement, which works with original Medicare. If you choose this option, you need a stand-alone PDP. Knowing this information should help you decide who to listen to- your children or friends.
Does Medicare cover health care services on a cruise ship?
Once you cross into International waters, your Medicare will not cover you. There are very specialized situations while traveling abroad where it does. Always take the travel insurance.However, adding a proper supplemental plan to your original Medicare can provide a $50,000 lifetime reimbursement benefit to augment your billing.
Are Medicare Supplement plans the same thing as "Medicare Secondary Insurance"?
Yes. Medicare supplement plans are often referred to as Medigap plans. These plans work in conjunction with your traditional Medicare, but do not take the place of traditional Medicare, as Medicare Advantage plans do.
My income fluctuates significantly year to year from investment distributions. How can I avoid IRMAA surcharges when I have an unusually high-income year?
IRMAA charges are calculated each year based on your tax return of two years ago. In any one year, you have a fluctuation, you can appeal an IRMAA by filling out an SSA-44 form. this can be found on and downloaded from the SSA.gov website.
I'm taking a brand-name medication that doesn't have a generic version. How can I find a Medicare Part D plan that will cover it at a reasonable cost?
To find a Medicare Part D plan covering your brand-name medication, use the Medicare Plan Finder on Medicare.gov and input your medication, dosage, and preferred pharmacies to compare plans and costs.
I'm living solely on Social Security of $1,400 monthly and can't afford my Medicare premiums and copays. What assistance programs might help someone in my situation?
A person of this income level may qualify for Medicaid, which is a separate agency from Medicare, administered by individual States, for low-income folks. Apply through Department of Health and Human Services in your state. If you qualify for Medicaid, it can go along with your Medicare. This is referred to as dual-eligible (Medicare & Medicaid). Dual eligible individuals qualify for additional benefits. There is another program for low-income folks called Extra Help for Prescription Drug Costs. The income brackets for this program are slightly higher than those for Medicaid. Some folks qualify for Medicare, Medicaid and Extra Help for Prescription Drug Costs. If necessary, I'm able to guide folks in applying for Medicaid and/or Extra Help. Additionally, I offer benefit reviews at no charge, to see if I can offer you more benefits or lower premiums or both.I'm caring for my elderly parent with dementia. How can I get legal authority to manage their Medicare?
You will have to obtain a valid power of attorney (POA) or a court-appointed guardianship/conservatorship. It should explicitly grant the power to handle healthcare and Medicare-related decisions. If your parent cannot sign a POA, you will have to petition the court for guardianship/conservatorship.If you decide to petition the court, you will need to gather the necessary documents and information required by the state where you reside. You may need to provide evidence of your parent;s incapacity and why a guardian or conservator is needed. The court will likely conduct a hearing and may appoint an attorney to represent your parent's interests.
My friend gets SilverSneakers with her plan and I don't-how are we both paying for Medicare and getting such different stuff?
SilverSneakers and other fitness programs are benefits usually provided with the Medicare Advantage plans. Even though both of you are on Medicare, there is a difference in the plans you enrolled in.The fitness programs are not included with Medicare Supplement plans or in Original Medicare Part A & B. To receive that benefit, you would need to sign up for a Medicare Advantage plan with the fitness benefit included.
What advice would you give to seniors who are feeling overwhelmed by all the Medicare options available?
Medicare can be very complex and confusing, you can be new to Medicare and feel overwhelmed by all the terms, but even people on Medicare for years can still find themselves overwhelmed when looking at switching plans. This is why it is so important to work with a local Medicare agent or broker that is licensed and able to explain plan benefits and copays. Having a Medicare broker or agent should never cost you anything to be their client. If you decide to switch or enroll with one you may contact them with any questions you have on your plan, instead of calling a carrier yourself. ALLOW ONE INITIAL APPOINTMENT with an agent before contacting them with questions or concerns.My friend lives in a different city and has a much more detailed Medicare plan. Is their plan dependent on their location?
There should be little to no difference in coverage between traditional Medicare Part A and B and with a Medigap plan. Of course, some states require a few extra details in the Medigap plans, such as prevented care items.Medicare Advantage plans differ in some ways in providing requirements and services within and between states. These decisions are not Medicare decisions. They are based on the insurance carriers that provide these Advantage plans and the individual state regulations.
Are there any tax benefits tied to paying Medicare premiums as a retiree?
Ultimately that is a question for a tax professional. It depends on many factors such as income, tax brackets, and state of residence. I would ask a qualified tax professional.
I've had a change in my health condition. How does this affect my current Medicare plan, and should I reconsider my coverage?
If you have a severe or disabling condition that recently occurred and are enrolled in a Medicare Advantage plan you may qualify a (SEP) Special Enrollment Period.If you have a Medigap plan most likely no changes will be needed.
How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?
To appeal a decision by original Medicare, contact Medicare. If your Part D plan is denying prescription drug coverage, have will need to request that your doctor file for a "formulary exception" with your insurance. If the insurance company decision is to deny the requested exception, you need to feel an appeal with your insurance. The recommended plan of action for an insurance company's denial of coverage for a specific procedure is you need to contact your insurance company and file an appeal of the denial. Your independent Medicare health insurance agent (who sold you the plan) most assuredly should be able to help you.
What's the most cost-effective way for a healthy 65-year-old to structure their Medicare coverage?
It all depends on your situation and needs. Most senior beneficiaries save money by enrolling in a Medicare Advantage Plan in their area but that may or may not be what is best for them specifically.
I've heard about Medicare fraud. What steps can I take to protect myself from scams related to Medicare?
To protect against Medicare fraud, be as vigilant a you would with your credit cards and financial accounts. Don't share your information with anyone unless you know exactly who you are talking with. Check your Medicare claims history and use your login at www.Medicare.gov website to review your claims. If you see charges for services you never received - notify Medicare. Be careful of phone calls asking for your private information, your Medicare ID, social security number, etc. These are red flags.I have a family history of colon cancer. Will Medicare cover more frequent colonoscopies for someone in my situation?
If someone is deemed to be at high risk for colon cancer, Medicare will cover frequent colonoscopies every 2 years. Your doctor or other health care provider may recommend you get services more often than Medicare covers. An additional plan such as a Medicare Supplement or a Medicare Advantage can provide such additional coverage.
Shouldn't Medicare do more to address health disparities among minority seniors?
That seems to be more of a question to ask your representative. There are many gaps that could be addressed by Medicare and our representatives need to hear from you to seek ways and means to make Medicare better for all.My husband passed away and now my Medicare premiums went up. Why does losing someone raise your costs?
This can be complicated. It has to do with you & your husband's "Adjusted Gross Income" or "AGI" which is taken from your 2-yr. old tax return. If you've earned more than your husband during your respective careers, once he is out of the picture, Medicare only looks at your new and "individual" tax return. The least amount in 2025 for the Part B premium is $185.00 (as an individual filer, that means the "AGI" is $103,000.00 or less; but it can be as much as $594.00 per month if your AGI is $500K or greater). My best advice for you would be to make an appointment with a counselor at your nearest Social Security office to verify that the above example happened to be your case, or not.
Why did I receive a Medicare Summary Notice, and what should I do with it?
A Medicare Summary Notice (MSN) is a quarterly statement sent to individuals with Original Medicare (Parts A and B) that summarizes their claims for services and supplies billed to Medicare during that period. It details what Medicare paid, what you owe, and if the service was approved. MSNs are not bills; they are a record of claims and payments. There is nothing you need to do with the statement.
My Medicare Advantage plan denied coverage for a specialist I need to see. What are my options now?
Your primary care physician may need to make the referral before its approved by your plan, especially if you have a HMO plan vs a PPO or HMO-POS plan where you can select specialists on your own instead of through your primary care provider. The other situation is the specialist you selected may not be in network. Again with HMO plans you always need to stay in network. With a PPO plan, you can choose a specialist who is not in network, but you will pay significantly more if you do. Check either with your agent or the customer service to find out what your options are to resolve this issue.
I need help at home after my surgery. Will Medicare cover a home health aide or am I on my own?
Yes, Medicare can cover home health aide services after your surgery, but certain conditions must be met.Eligibility Criteria:
To qualify for Medicare-covered home health services, you must:
Be under the care of a doctor who certifies that you need intermittent skilled nursing care, physical therapy, speech-language pathology, or continued occupational therapy.
Be homebound, meaning it's difficult for you to leave your home without assistance due to your medical condition.
Boost Home Healthcare
Receive services from a Medicare-certified home health agency.
Services Covered:
If you meet these criteria, Medicare may cover:
Part-time or intermittent skilled nursing care (e.g., wound care, injections).
Therapy services, such as physical, occupational, or speech-language therapy.
Home health aide services, which provide personal care like bathing and dressing, but only if you're also receiving skilled care as mentioned above.
Medical social services to help with social and emotional concerns related to your illness.
Certain medical supplies and durable medical equipment (e.g., walkers, wheelchairs).
Limitations:
Medicare does not cover:
24-hour-a-day care at home.
Meals delivered to your home.
Homemaker services like shopping, cleaning, and laundry when these are the only services you need.
Custodial or personal care that helps you with daily living activities (like bathing, dressing, or using the bathroom), when this is the only care you need.
Isn't it suspicious that Medicare Advantage plans offer gift cards and incentives to enroll?
I do not feel it is suspicious, but it is against regulations. Offering such gift cards to entice a beneficiary to enroll is not permitted.Offering gift cards to beneficiaries for completing health assessments is permitted, but not for enrollment.
I'm a smoker trying to quit. What smoking cessation benefits does Medicare offer for someone in my situation?
Medicare provides some support to help beneficiaries who are trying to quit.Medicare Part B covers a variety of preventive services, and smoking cessation counseling is included.
Medicare Part D (prescription drug) plans may cover prescription medications or nicotine inhalers and nasal sprays that require a prescription.
Won't Medicare run out of money before I can benefit from it?
Medicare and Social Security are two different government accounts and departments. Medicare is funded by Congress each year out of the same bucket from which our federal military receives its money.On the other hand, our Social Security accounts are sovereign from other Government activities. That means that what goes into the Social Security account is only paid out to Social Security benefits.
The Social Security account is fully funded until around 2035, and after that, Congress will have to subsidize Social Security payments. It has been stated that after 2035, not enough money is being paid into the Social Security account as Social Security is paid out.
Isn't Medicare headed for a crisis with so many baby boomers aging into the system?
This is known very well by the Medicare market and it is pretty much going to hit its peak by 2030. This is not a surprise as it’s been known for a very long time. There may be changes and adjustments made but it isn’t going to blindside the industry.Isn't it time for Medicare to completely overhaul how it approaches senior care?
This is a long-time debate. Some feel we need to privatize Medicare, and others feel we need to let the government control it under a one-plan-for-all. Health decisions are very private, and with that being said, many areas in the Medicare system need to be adjusted or approved, along with the idea of using newer technology.
How can I avoid or reduce IRMAA charges on my Medicare premiums?
The fact is IRMAA charges are calculated based on your AGI (Adjusted Gross Income) from 2 years ago. Know this may give you and your tax accountant time to do some financial planning that will help you pay less IRMAA charges when the time comes. You can do a Google search to see the levels of additional IRMAA charges that will be added to your base Medicare premium.I'm an independent agent and am compensated for my services by the insurance companies. I never charge you additional fees for my services. I'm asked this question (IRMAA charges) quite often by higher income earners. You can contact me at 801-550-1800 to answer questions that will help you better understand what to expect.
How do I budget for Medicare costs if I expect my health to decline in the next decade?
If you expect your health to decline over the next decade, it’s smart to plan ahead for higher medical expenses. Start by choosing a Medicare plan that offers good coverage for frequent doctor visits, specialists, and prescriptions. Consider a Medicare Advantage PPO if you want flexibility, or Medigap with Original Medicare if you prefer predictability and nationwide access.Also, budget for the “hidden” costs like copays, coinsurance, dental, vision, and long-term care, which Medicare doesn’t usually cover. If you can, set aside a health savings cushion or look into plans that offer extra benefits, like an Advantage plan with a spending card or over-the-counter allowance.
Lastly, review your coverage every year during open enrollment. Your health needs will change, and so should your plan.
How does getting married late in life affect my Medicare coverage or costs?
Getting married later in life may affect your Medicare coverage and costs in a variety of ways. If you file a joint tax return with your spouse, higher income may affect your Medicare part B and part D premiums. Medicare charges beneficiaries more in part B and part D premiums if they are in higher income brackets. Marriage may also affect your assets which may affect your ability to get some sort of aid such as extra help and or Medicaid. I recommend speaking to a Medicare expert and a financial advisor as to your specific situation.What should I do with my Medicare plan if I'm diagnosed with a rare disease requiring specialists?
Your actions depend on what kind of plan you're on. If you have Medicare Supplement, you may go to any doctor in the US who accepts original Medicare as payment.If you have a Medicare Advantage plan, you may have a PPO, an HMO, or a similar plan. If your plan is a PPO, you have a choice of going to a specialist in or out of network. In-network doctors have lower co-payments than out-of-network. You can check your Evidence of Coverage for your share-of-cost.
If you have an HMO, you will need a referral from your primary care physician to see a specialist. When your doctor writes the referral, ask him/her to mark it as urgent. This will speed up the processing time. Remember that Medicare Advantage is required to provide care at least as good as Original Medicare. Hold your health plan to that standard. Remember that you are your own best advocate. Best wishes to you and please contact me if you have questions.
I'm considering concierge medicine but already have Medicare. How would these work together?
I have met with a local concierge Dr and she requested that if working with Medicare advantage, PPO plans would be a good fit since they are not in-network with the Medicare advantage plans. As of recently, one of the local health plans told me their HMO plan does work with concierge. So it sounds like they are more flexible now, don't need a PPO is what I've been told!I'm worried about affording my medications even with the 2025 changes. Are there additional assistance programs I should know about?
Even with the coverage gap being eliminated and a max of $2000 out-of-pocket being set, medications can still be costly.Medicare Beneficiaries can:
1) Apply for the Low-income Subsidy (extra help) through Social Security
2) Apply for the state-based program called the Medicare Savings Program
3) Apply for patient assistance programs offered by the drug manufacturers or non-profit organizations.
I'm on a fixed income and struggling to afford my medications. What's this Extra Help program I've heard about for Medicare Part D?
Extra Help is made available to lower income seniors on Medicare that require financial assistance to pay for their prescription drug costs. This may include: premium, deductibles, copays, etc. You must meet certain income requirements to qualify for this program and you can contact your local Medicare Agent or your local SSA office.Don't you think Medicare's focus on treatment rather than prevention is backwards?
I do agree. The dilemma here is that due to the scarcity of Primary doctors in the US, focusing on prevention rather than treatment (in the long run) will be less expensive to Medicare. In our global economy, this is "the formula" that healthcare has adopted. Moreover, there are two specific kinds of "codes" that are placed in your record after a visit: A) "Preventive", and, B) "Diagnostic", the latter of which will come out of either Part A (in-patient) and Part B (out-patient) Medicare, therein costing the Feds the extra money. However, when a person sees her/his doctor without complaining of any type of pain, that visit is automatically coded as Preventive, thus costing the patient more $$ rather than the Federal government. The exception to that is, for example, if you're having a colonoscopy and the surgeon removes some polyps which have to be analyzed, if it has been found to be cancerous, it will change codes from a preventive visit to one that needs further discussion and thus is now diagnostic.
I've been diagnosed with bipolar disorder at age 66. How should I structure my Medicare coverage to ensure I get the mental health care I need?
Medicare Supplements and Medicare Advantage plans cover mental health visits and hospitalization due to mental health. Part D prescription drug plans cover medications. Please contact your agent to see if your medications are covered. If you do not have Medicare yet, please contact a local agent to help you.
I want to be proactive about my health. What preventive services should I be taking advantage of with Medicare?
medicare has a standardized list of preventive services that are covered as well as as a standard frequency when you should be getting these screenings. Your summary of benefits should have a list of these in your preventive services section. Sometimes the frequency can vary based on medical history and necessity. It’s important to work with your doctor to determine if your screening should be done more frequently than the standard.I'm in the donut hole and can't afford my medications. What are my options right now before the 2025 changes?
This year of 2025 there are no known holes in the prescription drug plans. All drug plans are mandatory with this feeling of $2000 out-of-pocket expenses for the beneficiary. However, it is important to make sure that your drug plan includes your prescription drugs in their formulary so that you get full benefit of the out-of-pocket expenses.All part D prescription drug plans should be reviewed annually
Why does Medicare allow insurance companies to bombard seniors with confusing mail and TV ads?
I wouldn't say Medicare allows it; however, private insurers aggressively market Medicare Advantage plans to gain enrollment and sometimes use tactics that can be confusing.Some ads or mailings can be misleading, such as promising benefits at a specified amount that isn't correct.
Medicare beneficiaries are more vulnerable. That's why I recommend working with a broker you trust to handle your insurance needs. I tell all of my clients to call me with any questions they have about anything they see on TV or receive in the mail. This is my way of protecting them from being enrolled in a plan that isn't a good fit for their situation.
Most of the time, the people on the phone you reach to go over your benefits, don't discuss all aspect of your needs such as medications, doctors, etc.
I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?
My concern would be why did they deny it.Home Health Care is a Skilled Nursing Code.
Doctor has to certify that you are home bound and that you need a nurse to come in and do basic MEDICAL needs for you. Example is wound care or Medicine care and PT.
They don't stay very long. They come in and do the medical care needed and leave.
They would have to have a reason why you can come to them to get approved.
It is also only approved for 30 days and can be extended if the doctor approves it. It has to be recertified every 60 days. It is meant for short term and that you are healing and getting better.
If you need it all the time and your not getting better then that will be under Long Term Care. That is a separate policy and not covered by Medicare.
If you want to file an appeal here is the link:
https://www.medicare.gov/providers-services/claims-appeals-complaints/appeals
I exercise regularly and maintain a healthy lifestyle. Does Medicare offer any incentives or additional benefits for preventive health behaviors?
A few Medicare Supplements and some Medicare Advantage plans have a benefit for gym memberships. Some Medicare Advantage plans will pay you a specific dollar amount for preventative visits. I would not choose a plan based on these benefits. Focus on the quality of the medical coverage. Please contact your local agent for more information about the plans in your area.Don't you think Medicare should ban all those celebrity Medicare Advantage commercials?
In my opinion, yes. They are misleading and cause a lot of confusion with Medicare beneficiaries. I usually have to address misinformation caused by those commercials on a daily basis
I'm at high risk for heart disease based on my family history. What additional preventive services might Medicare cover for someone with my risk factors?
Based on family history of heart disease, you may consider a Medicare Supplemental Plan, to go along with your original Medicare, this would give you the best coverage if you encountered major issues so your medical expenses would have the best coverage available to you.What are some lesser-known benefits or services that my Medicare plan might cover that I could be missing out on?
This is a perfect question, and a great one especially in today’s time, as Medicare Advantage plans are introducing more creative and innovative benefits to differentiate themselves. You might find lesser-known Medicare Advantage perks like quarterly allowances for rent, utilities, groceries, over-the-counter items like pain relievers, or even transportation to medical appointments and gym memberships for wellness programs. Meanwhile, Medicare Supplement plans, such as G or N, often include a valuable international travel benefit for emergency care abroad, which can be crucial if you’re overseas and need treatment unexpectedly.Browse Other Questions & Answers
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