Medicare Questions & Answers: Coverage
Coverage Q&A
Showing 129 questions
Does Medicare cover eye exams, or are seniors left paying too much?
Original Medicare (Parts A and B) doesn't cover routine eye exams for glasses or contact lenses, it does cover certain eye exams and treatments related to specific conditions like glaucoma, diabetic eye disease, and macular degeneration, as well as cataract surgery. Some Medicare Advantage plans do however give the extra benefit of eye exams and glasses.
Am I eligible for a Special Enrollment Period if I lose employer coverage?
Yes, you may be eligible for a Special Enrollment Period (SEP) if you lose your employer health coverage. This SEP typically lasts for 8 months following the loss of your coverage, allowing you to enroll in Medicare without facing penalties. It's important to inform Medicare of your loss of coverage to ensure a smooth enrollment process
Which Medicare Supplement plan (Medigap) offers the best value for most seniors, and why?
Plan G is usually the best value for most seniors. It covers almost everything except the Part B deductible, making it a solid choice for predictable costs and great coverage. It’s popular because it offers the most benefits without the high premiums of Plan F. (Which is only available for those eligible for Medicare before 1/1/2020) Plus, once the deductible is paid, there are no copays or surprise bills.
Is Medicare Part A enough for hospital coverage?
Part A covers hospital stays, but it is not always enough on its own. Most people need more than Part A.Consider Part B, covers Doctors, outpatient services and diagnostic testing.
Consider Medicare Supplement or Medicare Advantage, Part C.
Consider part D, prescription drugs.
What does Medicare Part B cover? Is it enough?
After a $257 deductible (in 2025), part b covers 80% of most medically necessary services when using a doctor or facility that accepts medicare assignment. Some places may charge 15% more, but still accept Medicare patients. You or your supplement would be responsible for the excess charges.
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.
Is paying for a high-end Medicare Supplement plan really worth it, or is it overkill?
I believe buying the best Medicare Supplement plan available is the smart move. It costs more upfront, but the lower financial exposure and stronger benefits outweigh the savings from cheaper plans with weaker coverage. Most clients I’ve guided find the trade-off worth it when they need serious care. You’re not overpaying—you’re securing peace of mind.
What's an underrated benefit of Original Medicare that many people overlook?
The most underrated benefit of Original Medicare is freedom of choice. With Original Medicare you can see any provider as long as they take Medicare. no referrals are needed and it travels well. The coverage is Nation wide.
How can I get dental and vision coverage with Medicare?
Medicare does not cover dental and vision however you can get those options with some of the Medicare Advantage plans that are available.Does Medicare fully cover nursing home care, and are there alternatives?
Medicare does not fully cover nursing home care. It only provides limited coverage for skilled nursing facility care under certain conditions, such as after a qualifying hospital stay of at least three days. Even then, Medicare typically covers only the first 20 days fully, with beneficiaries responsible for a daily copayment for days 21 to 100.For long-term care in nursing homes, Medicare does not provide coverage. Alternatives for covering these costs include Medicaid for those who qualify based on income and assets, long-term care insurance, or personal savings. It's important to explore different options well in advance to ensure a comprehensive plan for potential long-term care needs.
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.
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?
One, no one should ever pick a plan because their "friends" say it's better. I cannot tell you how many people made that mistake. Medicare insurance needs are different for everyone.Two, she should be concerned about her doctors accepting the insurance because Medicare Advantage plans are network plans. But that is why you have me as a broker to check all the networks to make sure your doctors accept the plan you may be switching to.
My Medicare Advantage plan listed my doctor, but now they say he's out of network. How is that even allowed?
That can be frustrating! Medicare Advantage plans typically have contracts with specific networks of doctors, hospitals, and other healthcare providers. However, sometimes these contracts change throughout the year. Even if your doctor was in-network when you enrolled in your plan, they might have been removed from the network later due to changes in the insurance company’s agreements or policies.Unfortunately, this can happen, but you do have some options.
I just got a $300 bill for an ambulance ride I thought was covered. Am I the only one who didn't know Medicare doesn't pay for all emergency transport?
Medicare does pay for covered ambulance service but certain criteria must be met. There is a $257 Annual deductible for all medical costs that must be satisfied and a 20% coinsurance on all ambulance services. Consult with a licensed agent to find out what the criteria is that you have to meet in order for it to be a covered service. Supplement/MediGap pland and Advantage plans include coverage for Ambulance services as well.
Does Medicare cover emergency care if I'm traveling in a U.S. territory like Puerto Rico?
Yes(Si), you have coverage anywhere in the US and its territiories with Medicare and Medicare Plans, including Puerto Rico.
I have multiple medications; how can I ensure my Medicare Part D plan covers them all without breaking the bank?
medicare.gov has a public website allowing you to input your Rx list including name of drug, milligrams and dosage. Then key in your pharmacy preference to see which Medicare Part D plan will give you the best bang for your buck.
If I need long-term care in the future, how does Medicare fit into that plan, and what should I be doing now to prepare?
This is a great question and I am pleased to hear that you are thinking about this proactively.Unfortunately, Medicare does not cover long-term care, such as your stay in a nursing/retirement home or having someone come to your own home daily for custodial care (bathing, dressing, feeding, ect.).
You should consider discussing a Long-Term Care policy with your agent/broker.
One thing to note is that as you age, these policies become more expensive. In many cases, people faced with the situation to enter Long-Term care may have to apply for Medicaid in order to receive any financial assistance or cover their costs. In some cases, extended family members may be able to contribute, however it can end up being a hefty financial burden.
Will my Medicare plan work when traveling to Europe?
Traditional Medicare with Parts A and B and a Medigap plan F or G, could cover up to 80% where Medicare is accepted. Medicare Advantage plans would need prior approval from the insurance company that is carrying the plan.I need a hearing aid but I've heard Medicare doesn't cover them. Is there any way around this?
Original Medicare (Parts A and B) does not include Hearing Aid Coverage. Medicare Advantage often times does but not all plans so check closely on the plan if you are enrolled into Advantage. Supplement plans typically do not include Hearing Aid coverage but may include a discount plan or a rider for purchase with certain carriers (in certain states only).
I've been diagnosed with prediabetes. What preventive services does Medicare cover to help prevent progression to type 2 diabetes?
Its always a tough when you hear about any diagnosis from a Health Care professional regarding Diabetes. If you watch the news at all, you know that any Diabetes related health condition is serious and effects a large part of our population. Medicare provides several "Preventive Services'" that come at low or no Out of Pockets costs. Medicare Diabetes Prevention Program (MDPP) is a comprehensive One Time health behavior change program is available to help you prevent Type II diabetes. Common services like Diabetes Screening and monitoring, Medical Nutrition, foot exams and Hemoglobin A1C, Glaucoma Screenings as well as "Welcome to Medicare" preventive visits are design to address your diagnosis and prevent it from getting worse! Your Medicare agent can educate you on what is available to you! If you are new to Medicare you will love it!I just moved to a new state. Do I need to do anything with my Medicare coverage?
Yes, you will have 60 days to make a change upon arrival into your new state. This will vary by the type of plan you are enrolled in. Consult with an agent to avoid any penalties and missing deadlines.
My Medicare Advantage plan covers dental, but I can't find a dentist who accepts it. Is this a common problem?
Yes, not all plans use the same carrier for dental, and some differ between HMO and PPO. However they all have a provider search tool that we can assist with.
My Medicare Advantage plan advertised dental coverage, but it barely covers anything. Is this normal?
Dental coverage like most coverages vary from company to company and plan to plan. When sitting down with your Medicare or Health Insurance Broker, be sure to mention any services you hope to have done or coverages you’d like to make sure you have. This way, your Broker can find a plan that is tailored for your needs and expectations.
My friend said she got a free annual physical with Medicare, but my doctor billed me. What's going on?
Annual physicals are always free with Medicare. Perhaps your doctor is not in network? Your agent should always check and ascertain that your primary care physician is in network.I thought I was covered during my snowbird months in Florida, but apparently not. What kind of plan do I actually need for that?
If you have traditional Medicare and a Medicare supplement plan, also known as Medigap, then you are covered. However, if you are on a Medicare Advantage plan, you need to ensure that your healthcare providers are in your plan's network.
I picked a PPO for the flexibility, but now every time I go out of network the bills are outrageous. What's the point of even having a PPO?
I totally understand your frustration!Having a PPO (Preferred Provider Organization) plan is supposed to give you flexibility and freedom to choose your healthcare providers, both in-network and out-of-network. But, when the out-of-network bills start piling up, it can be overwhelming.
The point of having a PPO is to have access to a wider network of providers, including specialists, without needing a referral. However, it's essential to understand that out-of-network care usually comes with higher costs.
To avoid surprise medical bills, it's crucial to:
- Carefully review your PPO plan's network and coverage
- Verify the network status of your healthcare providers
- Understand the out-of-network costs and billing procedures
If you're feeling overwhelmed or unsure about your PPO plan, I'm here to help!
As a licensed health insurance broker, I can guide you through the complexities of Medicare and health insurance. Let's work together to find a solution that fits your needs and budget.
Call me today at 407-244-6951 to schedule a consultation. Let's navigate the healthcare system together and find a plan that gives you the flexibility and affordability you deserve!
I called to ask about a knee replacement and suddenly they said I need prior authorization. I thought my plan was supposed to be good-what's going on?
If you have a Medicare Advantage plan thy could ask for a prior authorization. It also could depend on the healthcare provider, or weather it is an HMO or a PPO.
Why might Original Medicare with a Part D plan be better than a Medicare Advantage plan for frequent travelers?
It really isn't since original Medicare only pays 80%, the member is responsible for 20% of everything which can become costly. and you have to PAY for Part D every month & pay for your medication. A Medicare Advantage Plan includes drug coverage with Tiers 1 & 2 usually $0 costs , depending g on the plan
I just got Medicare Part A, and I'm worried about hospital stays. How do I know if my overnight stay will be covered fully?
Overnight stay in hospital can be classified into two statuses (Inpatient and outpatient admission). If your doctor ordered that you need to be admitted to the hospital as an inpatient for medical care overnight, Medicare Part A will cover the cost of your hospital stay, including drugs, accomodation and meals for the first 60 days after you meet your Part A deductible which is $1,676.00 in 2025, for each benefit period. You will also pay coinsurance for days 61-90 of each benefit period.If your doctor ordered that you be admitted as an outpatient for observation only, overnight, Medicare Part B will cover the costs, not Part A.
In what situations will Medicare pay for medical services in a foreign hospital?
Medicare covers services in a foreign hospital in three situations. First, if you have a medical emergency in the U.S. and the foreign hospital is closer than the nearest U.S. hospital that can treat you. Second, if you are traveling through Canada without unreasonable delay between Alaska and another state and a medical emergency occurs, and the Canadian hospital is closer than a U.S. hospital. Third, if you live in the U.S. and the foreign hospital is closer to your home than the nearest U.S. hospital that can treat your condition, regardless of whether it is an emergency.
Is it true that Medicare pays for dental implants?
Who told you that? It does not! A few Medicare Advantage plans MAY have dental coverage that includes implants, but Original Medicare itself does not.I need a new wheelchair, and I'm not sure if Medicare will cover it. What's the process for getting durable medical equipment?
Original Medicare pays for DME, unless noted anywhere within its policy Medicare Advantage plans do not.You will have the 20% Co-pay responsibility, unless you have a Supplement plan that covers those charges.
That is an important feature in keeping your Original Medicare pays- it handles your DME, Medicare Advantage is typically handled Out-of-pocket by the insured.
I use a continuous glucose monitor for my diabetes that connects to my smartphone. Will Medicare cover this technology for someone with my condition?
Yes. “DME” stands for Durable Medical Equipment. A glucose monitor is paid for by most Medicare Supplements (aka, a Medigap plan). Go to medicare.gov and put DME in the horizontal search box. You will find that a Medigap covers over 60,000 treatments while an Advantage has a high deductible which, depending on the company, will potentially provide partial coverage for the monitor.Does Medicare cover Ozempic and other drugs prescribed for weight loss?
Approving a medication by Medicare is always based upon the justification of the medical necessity of that drug. The insurance company that underwrites the medical prescription drug plans lays out their drug plans each year to determine what will be covered under what plan. This is the time when you sit down with your Agent and review every drug plan for your ZIP Code with your prescription drugs. This is the best answer I can give you for now without knowing which drug plan you choose, and usually, there can be justification given for a weight loss drug being required.
My friend gets SilverSneakers with her plan and I don't-how are we both paying for Medicare and getting such different stuff?
A Silver Sneakers gym membership may be included in some Medicare Supplement plans, and it can also be part of some Medicare Advantage plans. But that benefit is not uniformly offered by ALL plans. If this is important to you, be sure to ask if Silver Sneakers or other gym membership is offered as a benefit under the plan you are evaluating.
I picked a Medicare Advantage plan because of the dental and now I found out it only covers cleanings. Why didn't anyone tell me this upfront?
Most Medicare advantages cover more than cleanings. If you worked with a broker you needed to ask them how the dental works and what they will Cover. You can also call me and I can adviseI'm on a supplemental Plan N, and I'm curious if my recent MRI is covered or if I'll get stuck with a big bill.
With your Medicare Supplement Plan N, your recent MRI is covered under Medicare Part B as long as it’s deemed medically necessary, but you’ll need to meet the 2025 Part B deductible of $257 first, and then Plan N picks up the 20% coinsurance—though you might face a small copay, up to $20, if it’s done in a doctor’s office. Unlike Plan G, which also covers the Part B coinsurance but skips those copays and fully handles excess charges if a provider bills above Medicare’s rate, Plan N leaves you responsible for any excess, though that’s rare with MRIs since most imaging centers stick to Medicare-approved amounts. I’ve seen beneficiaries caught off guard by these details, so double-check your provider’s billing with your Explanation of Benefits to avoid surprises—either way, your bill should stay manageable compared to having no supplement at all.I've been paying into Medicare for years, and I'm not sure why my specialist visits still cost me so much. What am I missing here?
Even with Medicare, specialist visits can cost money due to deductibles, coinsurance, and potential charges from non-participating providers. Medicare typically covers 80% of the Medicare-approved amount for most services, meaning you'll need to pay the remaining 20% (coinsurance) after meeting your deductible. Additionally, if your specialist doesn't accept Medicare assignment, they may charge you more than the Medicare-approved amount.I'm on Medigap Plan G, and I'm curious how my upcoming knee replacement surgery will be billed. Does the plan cover it all after my deductible?
You should not have any other out of pocket cost as long as you have met our yearly deductible. 2025 is $257
I'm on Original Medicare with no supplement, and I'm wondering how much I'd pay if I need an ambulance ride to the hospital tomorrow.
Without a Medicare Supplement, it falls under Original Medicare, Part B.The key thing is that it be considered medically necessary.
That can even include transport from a hospital to a skilled nursing facility - not just transportation toma hospital.
I picked a Medicare Advantage plan last year, and I'm not sure if my hearing aids are covered. How do I figure this out?
1. Call the member services phone number on the back of your card, and inquire as to how the hearing aid benefits work with your specific Advantage plan.2. or, call the Agent/Broker who helped you enroll in the Advantage plan. He or she should be able to give you the main points of the hearing aid benefits and then point you to phone numbers for third party contractors who provide the hearing aid benefits to this plan.
3. or, obtain the EOC (Evidence of Coverage) pdf document that outlines in detail how all the benefits work, for your plan.
I'm worried about the 'donut hole' in my Part D plan. How do I manage my medication costs once I enter it?
Don't worry! The dreaded "donut hole" has been discontinued effective January 1, 2025. So you can not longer enter the donut hole. However, Medicare pays less to the insurance companies this year for your prescriptions so most Part D plans now have higher deductibles which will be offset by a $ 2,000 annual limit on the full price of a member's covered Rx costs, so members with expensive name brand drugs will be protected by the new rules. Be careful on this and make sure that all of your prescriptions are in fact covered by your Part D plan.
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.
What should I do if I find out that my preferred hospital isn't in-network with my Medicare Advantage plan?
You can go to any doctor or hospital with Medicare Advantage. Although, there have been instances where a hospital drops the Medicare Advantage plan. You can switch plans during Medicare Advantage open enrollment, Jan 1 to March 31. If you can't find another plan to switch to, you could return to Original Medicare and you could also pair Original Medicare with Medigap.What do seniors often misunderstand about Medicare's coverage for long-term care?
They believe that Medicare covers LONG term Care and it does not ! That is why it's so imprtant to work with someone who knows ALL the specifics about Medicare and all the other options!Does Medicare Advantage cover home health care?
Yes, if your doctor orders it. However, Medicare does not cover 24-hour-a-day care at your home, home meal delivery, homemaker services (like shopping and cleaning) unrelated to your care plan, or 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. Some Medicare Advantage plans include some homemaker services when returning home from the hospital, so ask your broker.
Is Medicare's coverage for cataract surgery enough, or do seniors still face high out-of-pocket costs?
Original Medicare covers 80% of a variety of services including cataract surgery. Depending on how you subsidize original medicare your costs will vary. Medicare is a very individual choice and one to not take lightly. My job is to educate you on your choices to supplement and ensure you understand the pros and cons of each.If I need hospice care in the future, can my Medicare plan cover it?
Yes, under Original Medicare Part A, you are eligible for hospice benefits if a doctor certifies that you are terminal illness. These benefits cover your cost, even if you are enrolled in a Medicare Advantage plan. However, you will still need Medicare Part B and pay the monthly premiums. Depending on your Medigap plan or Medicare Advantage coverage, you may have some out-of-pocket expenses.I'm considering concierge medicine but already have Medicare. How would these work together?
Concierge Care will work with Medicare, but doctors may still charge you for some items that Medicare will not cover but may be covered under Concierge Care. Concierge services are not reimbursed by Medicare.This is good for having an extra layer of coverage. The premium for this coverage is not covered under Medicare, so this is one way to get extra insurance coverage and your Medicare. Medicare Advantage networks also work with Concierge.
Medicare does not reimburse concierge services, which provide this enhanced care.
I need home health care after my surgery, but Medicare denied coverage. What are my appeal rights?
You can always appeal. According to the Medicare Rights Center, 80 percent of Medicare Part A appeals and 92 percent of Part B appeals result in coverage for the beneficiary.
Don't you think Medicare's focus on treatment rather than prevention is backwards?
This is a complicated answer, how I look at it is Medicare is Based on Western Medicine that that focuses on treatment of conditions, so Medicare follow that process. However in my many years of doing this I have seen a lot of folks find out they have major health conditions because of the regular screenings that are at no cost to you on your policies. The plans do encourage you to use them and take advantage of no cost screenings and some doctor visits. So know that you are well covered. Now some plans do include no cost to you benefits, like gym memberships, access to over-the-counter products like vitamins and supplements, and other benefits that take aim at getting you and keeping you healthy! Make sure you choose a plan that fits your needs and lifestyle.
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.
I want to be proactive about my health. What preventive services should I be taking advantage of with Medicare?
There is a list of preventative services on Medicare.gov. Of course your annual physical, exercise and diet.
I'm a smoker trying to quit. What smoking cessation benefits does Medicare offer for someone in my situation?
Some Medicare Advantage Plans provide Smoking and Tobacco cessation counseling to stop smoking or tobacco use in the Medical Benefits. Some provide counseling visits over a 12 month period at no cost to you.I just moved from New York to Florida and have Original Medicare with a New York Medigap plan. Do I need to change my coverage?
You don't have to, but it is to your advantage to do so! I am a licensed Fl agent, and can explain it to you should you reach out to me. The plan itself most likely won't change, but the amount leaving your bank account will!! - Norman SmithI'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.
My doctor prescribed physical therapy, but I'm not sure how many visits Medicare will cover. How do I find out?
The number of physical therapy visits you get depends on what your doctor says. If the therapy is deemed medically necessary, Original Medicare will pay.However, if you have a Medicare Advantage plan and they deny the therapy, appeal the decision. MA coverage is required to be at least as good as Original Medicare so make sure your plan pays for what your doctor says you need.
I've heard Medicare covers home health care, but what exactly does that include?
Medicare generally covers part-time or intermittent home health care services when medically necessary, especially after a hospital stay or skilled nursing facility stay. This includes skilled nursing, physical therapy, occupational therapy, and speech-language pathology services, as well as medical social services and some home health aide care if it's related to skilled care. Medicare, however, does not cover 24-hour care, meal delivery, or personal care when it's the sole need. You can find more extensive break down online if you search or sit down with an agent sometime to go over all of it.I'm considering genetic testing to assess my cancer risk based on family history. Will Medicare cover this preventive approach in my situation?
Under traditional Medicare Part A and B with a Medigap plan, Medicare generally does not cover pre-symptomatic genetic testing for cancer risk assessment. However, with a doctor's order for the testing, it will most likely be approved for certain types of cancer testing. Some Medigap plans come with a rider that covers 100 percent of preventive care testing.Under the Medicare Advantage plan, these tests most likely will require prior approval from the insurance company.
I'm interested in a robotic knee replacement surgery that my surgeon recommends for my specific anatomy. How does Medicare coverage work for this advanced procedure?
Original Medicare: Medicare premium $185/mo, $257 deductible + (20% of $20,000 to $40,000 + post care costs)$5-10K no max out of pocket.
Medigap Plan G: $200-225/mo+
Medicare premium $185/mo, $257 deductible is your max out of pocket for the year
Medicare Advantage: Medicare premium $185/mo (may be reduced by up to $174,70/mo) specialist copay $10-$45+ outpatient hospital copay $100-$300 + post op rehab $20-$40/visit maximum out of pocket could be less than $500. Max out of pocket $1000-$6700.
I'm homebound and need remote monitoring for my heart condition. What Medicare benefits might apply to someone in my situation?
Yes, if your physician deems it medically necessary. However, some other EKG devices are most likely not covered by Medicare.I'm participating in a clinical trial for a new cancer treatment that uses personalized medicine based on my genetic profile. How does Medicare coverage work in this situation?
Medicare covers specific genetic tests if they are medically necessary and meet particular criteria. The cost of these procedures will be handled through expected Medicare benefits in payment. However, specialized clinics and procedures should always be verified for Medicare coverage before using them, and the medical necessity of such procedures must be demonstrated.
I want to get a shingles vaccine. Will Medicare cover this preventive service?
It does under Part D. There is generally no cost. Talk to your doctor and get a prescription. They will take it from there.My doctor recommended a bone density test. Is this considered preventive care under Medicare?
Yes, but it is covered under Medicare with a doctor's order. This test is generally covered only once every 24 months.My doctor wants me to get several preventive screenings. Will Medicare cover all of these at once?
Yes, Medicare covers many preventive screenings and services, often at no cost to you, as long as your doctor accepts Medicare and the services meet the guidelines.Can you explain what "creditable coverage" means and when it applies?
As it regards to Medicare, creditable coverage for prescription drugs means that your current coverage is as good or better than what is provided under the standard Medicare Part D benefit. And upon proof that you have had creditable coverage under your current health plan, you can delay Medicare Part D enrollment without incurring the dreaded Part D enrollment penalty.Will Medicare cover asthma and other breathing conditions?
Yes, Medicare will cover different inhalers and meds associated with asthma. It can be covered through Part B and/or Part D Medicare. Some equipment will be covered as durable medical equipment.I'm caring for my dad who has Alzheimer's with lots of medications and I keep getting bills I don't understand. Any tips for not drowning in paperwork?
It is difficult to answer this questions as there is NO information on what type of paperwork you are having difficulty with. A good agent , like myself can help a member navigate the challenges of bills/ co pay/ co insurances with Medicare
Will Medicare cover everything my current employer plan does?
Medicare may NOT cover all that your current employer plan does or has in the past. It is a great idea to always compare your current employer Health Plan to your Medicare plan options to find out what plans in your area cover.
I picked the plan with the lowest premium, but now every doctor visit feels like a surprise bill. Should I have gone with a higher premium instead?
Medica policies are very different from one another. You probably came up short with your needs analysis or listen to a friend who suggested their ““ Best” policy.A careful needs analysis and consideration for finances is the most appropriate way to determine which policy is “best” for you.
If you’d like assistance with this analysis, please contact me for a free consultation at 760-831-2736.
My plan covered my cataract surgery but not the lenses I actually needed-how do they get away with that?
Insurance plans, including Medicare, typically cover the cost of standard monofocal intraocular lenses (IOLs) for cataract surgery, but they often don't cover the extra cost of more advanced lens options like toric, multifocal, or extended depth-of-focus (EDOF) lenses. This is because these advanced lenses offer additional features beyond basic vision correction and are considered "premium" upgrades.My friend lives in a different city and has a much more detailed Medicare plan. Is their location dependent on their plan?
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.
What's the deal with Medicare covering medical equipment like wheelchairs- do I need a special approval?
Medicare Part B covers durable medical equipment (DME) like wheelchairs when deemed medically necessary, but you must have a doctor’s prescription and obtain prior approval from Medicare to confirm it meets their criteria, such as being essential for use within your home. This includes items supplied by Medicare-approved DME providers, though many beneficiaries don’t realize this until a need arises, often prompting a last-minute call to advisors for clarification. Without proper approval, coverage won’t apply, and you’d face full costs, so verifying these requirements early is key.How can I estimate my total Medicare costs if I have a chronic condition like diabetes?
Estimating your total Medicare costs will depend on how many doctor visits you have and the cost of any diabetic medicine you take which can be outlined in your Part D drug plan. I can provide you with a PDF outline of your costs.
How do I compare Part D plans to minimize costs for a mix of generic and specialty drugs?
You can always reach out to a professional broker for help in comparing Part D plans. Or, you can go directly to Medicare.gov and click on Health and Drug Plans in the upper right hand corner of the homepage. Then click on compare health and drug plans and enter your zip code. It will allow you to enter all of your prescriptions drugs and compare all available plans in your zip code. The comparison will also show what your monthly costs will be for each prescription. Don't hesitate to call for additional help!
What should I do with my Medicare plan if I'm diagnosed with a rare disease requiring specialists?
If you are on a Medicare Supplemental plan like a G or an N plan, you shouldn't be to concerned about the out of pocket cost that you will pay. If you are on a Medicare Advantage plan, just make sure your Specialist is in network.How does losing a spouse impact my Medicare plan if I was on their employer coverage?
When a client loses a spouse and was on their employer coverage, I explain they have 63 days to enroll in Medicare or adjust their plan without facing a penalty. It’s a qualifying event, so they’d need to switch to their own Part B if they’re 65, and I’d urge them to do it promptly to avoid any cost hikes or coverage lapses. The rules give them a clear path forward, but timing is critical.I'm on Medicare Part B, and I'm wondering how my physical therapy visits are covered. Do I have to hit my deductible first?
If your on Medicare A and B only you would 20%. If your on a Medicare Advantage Plan, it usually has a copay that would be deductible for the MOOP.I just started on Medicare Part D, and I'm confused about whether my new cholesterol medication counts toward my coverage gap. Can you explain?
Figuring out how your new cholesterol medication fits into Medicare Part D’s coverage gap can be confusing—it does count toward that limit, depending on your plan’s formulary and annual drug spending. In 2025, once your total costs hit the gap, you’ll reach catastrophic coverage after $2,000 out-of-pocket, lowering your costs to zero for covered meds, and Medicare now sends a statement detailing these expenses to keep you informed. Check that statement or your plan’s formulary for a clear snapshot of your progress!I've got Medigap Plan C, and I'm curious if my recent bloodwork is included or if I need to budget for extra costs.
This is no such thing as "Medigap Plan C". If you have a Medicare Part C Advantage plan, bloodwork / lab expenses will be plan dependent but many plans feature $ 0 copay (or low cost) for these services which can vary based on where the blood is drawn: doctor's office, clinic, hospital or other stand-alone facility.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.If Medicare Supplement (Medigap) plans are better for long-term coverage, why don't more people choose them?
Medicare supplement plans are generally much lower cost for people age 65 - to - 70 but after that, things change. I have customers who started paying $ 125 monthly for their supplements but their plans closed for new business and increased premiums on current grandfathered members to $ 500 monthly (and higher).Why does Medicare have so many coverage gaps, and is it designed that way on purpose?
In 1965, the government set up Medicare to help primary care for those over 65 with healthcare costs. President Johnson set it up to share healthcare costs between the government and beneficiaries. This was called the cost-sharing approach, with the intent to help control Medicare abuse and overcharge by discouraging unnecessary use of the services.Today, with healthcare costs rising, the original design has revealed six major gaps in its coverage. Therefore, yes, I think it was designed this way in the beginning, which makes it very confusing today. You need to make sure you have the right coverage and can’t afford the coverage of these gaps.
Can Medicare pay for my groceries?
Medicare itself doesn’t pay for groceries—Original Medicare sticks to medical coverage and doesn’t touch stuff like food benefits. But I’ve noticed more Medicare Advantage plans stepping up with ancillary extras, like grocery allowances, built into many options now, especially for folks with specific health needs. It’s not universal, though—depends on the plan and if you qualify, so you’d need to check what’s offered where you are.
How well does Medicare support seniors who need assisted living, or does it fall short?
Medicare does NOT cover Assisted Living facilities at all, You will need a long-term Care policy to cover that expense.Does Medicare cover hearing aids, or do I have to pay out of pocket?
No, some advantage plans do offer this coverage though in the form of free exams and copayments for the aids themselves. Costco and Sams also offer free exams and discounted aids.I need help at home after my surgery. Will Medicare cover a home health aide or am I on my own?
Yes, under traditional Medicare A & B with a Medigap plan, Medicare will cover some home health services after surgery. Under Medicare Advantage plans, this will require prior approval by the insurance companies that carry the plan.I have a family history of colon cancer. Will Medicare cover more frequent colonoscopies for someone in my situation?
Yes, under Medicare A & B, you may find that Medicare will cover your screening potentially every two years, under a doctor's order. Preventive care testing is offered as a separate rider with your Medigap programs, with some insurance carriers. These additional rider programs generally cover one hundred percent of the cost if classified as preventive care screening.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.I'm considering a smartwatch that monitors my heart rhythm for atrial fibrillation. Will Medicare help cover this type of wearable technology?
Traditional Medicare with a Medigap plan does not typically cover smartwatches, as Medicare standards have not approved them as medical devices under durable medical equipment (DME) monitoring devices. This is similar to a blood pressure kit that Medicare does not see as a medical necessity under DME monitoring devices. A Medicare Advantage plan may pay for the smartwatch, but it would require prior approval.I've heard Medicare covers an annual wellness visit. What exactly is included in this visit?
A Medicare Annual Wellness Visit focuses on preventative care and health planning, including a health risk assessment, review of medical history, and creation of a personalized prevention plan, but it's not a full physical
Does Medicare cover cancer screenings, and how often can I get them?
Yes, Medicare covers various cancer screenings, primarily through Part B, and the frequency of these screenings depends on the type of cancer and individual risk factors.
Why are hospitals not taking Medicare Advantage plans?
I am not seeing this issue in our area. Some plan may not be contracted out of state, but generally we find most Medicare Advantage plans are accepted wherever Medicare is accepted.Are mental health services like therapy fully covered under Original Medicare?
Mental health is covered but it is up to you to review different company policies since they could vary widely from state to state. There is a limited number of days that should be covered. It is incumbent upon you to fully understand those limitations. This is why it is imperative to go over with a knowledgeable agent who can easily differentiate between what an Advantage plan covers vs. what a Med. Suppmt. (Medigap) covers in this extremely important area.Can Medicare Part D deny coverage for a brand-name drug if a generic isn't available?
Medicare Part D can’t deny coverage for a brand-name drug just because a generic isn’t available—plans must cover it if it’s on their formulary and medically necessary, based on your doctor’s prescription, though they might require prior authorization or step therapy to justify it over other options. Upon enrollment, I always encourage my clients to call me if their medication regimen changes during the year so we can verify coverage details with the carrier and avoid surprises. I’ve dealt with this plenty, and as long as the drug’s listed and no generic exists, your plan has to honor it under CMS rules, but check your formulary or call your provider to confirm it’s not excluded or restricted. If it’s off-formulary, you’d need an exception, which can be a hassle but doable with your doctor’s help.
Does Medicare pay for telehealth visits with specialists, or is it limited to primary care?
Medicare's Part B allows for you to do telehealth with both a Primary Care and a Specialist. They are covered in the same way as if you wast to go in person.How does the Part D "catastrophic coverage" phase work once I hit the out-of-pocket max?
Once you hit the 2,000 max out of pocket everything is Covered 100%There is no Catastrophic phase anymore No donut hole
If I start dialysis, how does that change my Medicare eligibility or coverage?
Most people on dialysys are covered on their plan. A member on Medicaid-Medicare, all cost would be covered, depending on their plan & cost shareI've had a change in my health condition. How does this affect my current Medicare plan, and should I reconsider my coverage?
on Medicare Advantage Plans there is NO underwriting, so regardless of the health of someone, everyone can get a Medicare Advantage Plan is long is their Part A & B are in effect. Medicare Supplements require medical under writing and based on results could require much higher monthly premiums
I'm caring for my spouse with dementia and experiencing caregiver burnout. Will Medicare cover any mental health support for me?
Outpatient Mental Health Care (Part B):Covers individual and group psychotherapy with licensed professionals.
Includes annual depression screenings.
Covers psychiatric evaluations and diagnostic tests.
Covers medication management and injections received at a provider's office.
Covers partial hospitalization programs (PHPs).
Covers intensive outpatient programs (IOPs).
Covers other mental health services like substance abuse treatment, occupational therapy, and more.
My friend got her cataract surgery covered by Medicare, but they didn't cover the lens she wanted. How does that work?
Medicare does cover cataract surgery, and I have personally undergone the procedure. However, they only cover standard lenses, and you will need to pay extra if you want to purchase a premium lens or any other special types. These are considered luxury items or cosmetic options by Medicare and are not deemed absolutely necessary. Nonetheless, Medicare does cover the cost of the surgery as well as the standard lenses.
I keep hearing about free preventive services with Medicare. What exactly is free and what will I still pay for?
Medicare covers preventive services that per the Medicare.gov website are identified as exams, shots, lab tests, and screenings. They key benefit that Medicare does not specifically cover are Routine Physical Exams. The majority of Medicare Advantage plans do cover a routine annual exam and typically they are a $0 copay.It is really important when setting up a routine physical exam with your doctor or provider that you have a good understanding of what services will be provided. For example, lets say your Medicare Advantage plan covers the routine physical exam which would include all of the $0 copay screenings, shots, and lab tests covered by Medicare. Those items would be a $0 copay. I never use the word free and Medicare does not allow a broker to ever use the word free.
It is common though that a good provider will ask you if there are other things you would like to discuss during your visit. Those items could be outside of the routine exam and you might have a copay for that portion of your visit. Lets say for example that you wish to discuss shoulder or knee pain you have been having. Those discussions are generally beyond your preventive $0 copay services and could trigger a copay for you.
In conclusion, its important to know that Medicare encourages all consumers to stay healthy and obtain the preventive services that have a $0 copay. It would only be services beyond or outside of the routine physical exam, tests, labs, screening that you might see additional costs.
My Advantage plan says I need a referral just to see a dermatologist. I thought PPOs didn't require that - was I wrong?
You are correct. PPOs do not require referrals. But there are "office policies" that require one. The insurance company can't force the practice to not require one.Why do doctors not like Medicare Advantage plans?
I am not a Doctor, so I can only assume that they might not like Medicare Advantage plans too much because they may not get paid as much for certain services. Medicare Advantage plans are considered managed care plans, so many time the Dr and patient have to get prior authorizations for certain procedures, this could delay the patients care and take administrators time and energy.What are the 6 things Medicare doesn't cover?
Original Medicare does NOT typically cover: Please see pages 55-56 in your 2025 Medicare and you Handbook. If you want a digital copy, contact me and I will be happy to forward by email.1. Cosmetic Surgery
2. Massage Therapy
3. Hearing Aids and Exams
4. Routine Dental Care
5. Concierge Care
6. Eye Exams (for Prescription Glasses)
Good news is that some of these are covered in a Medicare Advantage plan. Dental/Vision can be covered in a Standalone Dental/Vision plan.
Contact a local broker to confirm these coverages in your local plan.
Does Medicare Advantage cover acupuncture or alternative therapies in some plans?
Yes Some Medicare Advantage plans may cover Acupuncture. Always check your Summary of Benefits. The Acupuncture benefit could be covered for chronic low back pain only. Not all providers could be included.also See page 30 in your Medicare and You Handbook 2025
How does Medicare Part B handle coverage for preventative screenings like mammograms?
Medicare Part B covers preventive screenings like mammograms as part of its focus on early detection and health maintenance, with specific rules on frequency, cost, and eligibility. Here’s how it works:Screening Mammograms: These are covered for women aged 40 and older to detect breast cancer early, before symptoms appear.
Frequency: Part B fully covers one screening mammogram every 12 months (anytime after 11 months from your last one). If you’re new to Medicare, you also get a baseline mammogram covered between ages 35–39.
Cost: There’s no out-of-pocket cost—no coinsurance, copayment, or Part B deductible—as long as the provider accepts Medicare assignment (agrees to Medicare’s payment rates). This applies to 2D and 3D (tomosynthesis) screenings, though 3D coverage was clarified in updates around 2018 to match evolving standards.
Diagnostic Mammograms: If a screening finds something abnormal or you have symptoms (like a lump), Part B covers diagnostic mammograms to investigate further.
Frequency: No strict limit—covered as medically necessary, which could mean multiple in a year if your doctor orders them.
Cost: After meeting the Part B deductible ($240 in 2025), you pay 20% of the Medicare-approved amount. There’s no cap on how many are covered, but each one triggers that 20% coinsurance unless you have a Medigap plan to offset it.
Key Details: The mammogram must be done at a Medicare-approved facility (like a radiology center or hospital outpatient department). If it’s bundled with other services (e.g., a biopsy), additional costs might apply under Part B’s standard rules. Preventive coverage assumes you’re symptom-free—once it’s diagnostic, it shifts to a treatment framework.
This setup reflects Part B’s broader approach to preventive care: full coverage for annual screenings to catch issues early, with cost-sharing kicking in when it’s about diagnosis or follow-up. It’s a balance between encouraging checkups and managing expenses when care escalates.
What's the cheapest way to get Medicare coverage if I only need basic hospital care?
The cheapest way to get hospital coverage is with Part A. Part A covers hospital charges at a 80/20 coinsurance rate. Medicare pays 80%, you pay 20%. Be aware, there is NO CAP on your 20%.
Do I need a Hospital Indemnity Plan if I have Medicare Advantage? What if I am hospitalized twice in the same year?
It's not necessary but you could face pretty high out of pocket costs.Advantage plans have deductibles and copays. The indemnity plan pays you a set amount by plan
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 both a psychiatrist for medication and a therapist for talk therapy. How does Medicare coordinate coverage for these different providers?
Medicare provides coverage for both psychiatric medication management and talk therapy through its Part B (Medical Insurance) and Part D (Prescription Drug Coverage) plans.Psychiatric Medication Management
Medicare Part B covers outpatient mental health services, including visits with psychiatrists or other qualified healthcare providers for psychiatric evaluations and medication management. After meeting the Part B deductible, you typically pay 20% of the Medicare-approved amount for these services if your provider accepts assignment. Provider Acceptance: Not all mental health providers accept Medicare. It's important to confirm with your psychiatrist and therapist that they accept Medicare assignment to ensure coverage. Medicare Advantage Plans: If you're enrolled in a Medicare Advantage Plan (Part C), your plan may offer additional mental health benefits beyond Original Medicare. However, provider networks can be more limited, so verify that your preferred providers are in-network
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?
If you’re at high risk for heart disease, Medicare DOES cover some extra preventive services that can really help.They’ll cover things like a cardiovascular screening every 5 years, that checks your cholesterol and other key levels. And you also get a yearly visit with your doctor to talk about heart health and how to stay on track with things like diet and exercise.
If your doctor sees any other red flags, there may be more services Medicare can cover, too, but it depends on your situation.
