Medicare Questions & Answers: Coverage
Coverage Q&A
Showing 132 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
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.
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.
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.
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.
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?
Yes. As long as the facility where you have the surgery accepts Medicare assignment, you will only be responsible for the Part B annual deductible ($257 for 2025). Once you pay the Part B annual deductible, Medicare will pick up 80% of the remaining bill, and your Medigap Plan G will pick up the other 20%. https://medicareagentshub.com/#
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 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.
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.
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.
Is paying for a high-end Medicare Supplement plan really worth it, or is it overkill?
The answer depends on your specific situation. In general, Medicare pays for approximately 80% of your medical expenses, not including deductibles. The high-end Medicare Supplement plans pick up nearly all of the remaining 20% (in the case of the Plan G, you pay one small deductible.) Depending on the procedures or extent of care, this could still be a large financial liability. So, each person must decide if the premium for these plans is worth the potential risk of incurring even this portion of any medical bills. For many of my clients, paying this premium gives them the peace of mind that those bills will be covered, if and when they need them, even if they don't need a lot of care at this time. To balance out this premium cost, Medicare Supplement plans give you the freedom to go to any Medicare provider in the whole nation. If you reside in a different state for several months out of the year, Medicare Supplement plans suite well. The flexibility and peace of mind of Medicare Supplement plans may be worth the premium cost.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 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.
My friend said she got a free annual physical with Medicare, but my doctor billed me. What's going on?
Medicare does not provide annual physicals; these are called wellness exams. If the doctor bills it as a physical, you will most likely pay 100%. However, if you have a Medicare Advantage plan, it may be covered as an annual physical under your policy coverage. All Medicare Advantage plans are different, and their coverage for these items varies; check your policy.Under traditional Medicare Part A and B, you can receive a yearly wellness exam. Talk to your doctor about the upcoming exam and what it entails.
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!
Why do doctors not like Medicare Advantage plans?
For Medical services and procedures, doctors need to bill the Insurance company you have your Medicare Advantage plan with. For certain services/procedures, pre-authorization is needed which takes longer with dealing with an insurance company.If you have a Medicare Supplement Plan (also called a Medigap plan) such as Plan F, G, or N then the billing and medical services pre-authorization request goes to Medicare direct, which is a simpler process.
Both billing and pre-authorization might just be simpler and quicker for the doctors to deal with. The administration with a Medicare Advantage insurance company might be more work for the doctors' administrative office.
Hope this helps ...
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.
You will have a charge of the Part B deductible first which as of 2025 will be $257 and then 20% of the charge of the ambulance company charge in your area (state/city) you live.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 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 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.
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.
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.
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.
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'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.
Does Medicare cover cancer screenings, and how often can I get them?
Cancer screenings are typically covered as a preventative service. How often depends on the carrier. Refer to the explanation of benefits for specific details as the amount may be different per carrier.
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 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.
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 advise
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.
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
Why might Original Medicare with a Part D plan be better than a Medicare Advantage plan for frequent travelers?
Original Medicare combined with a Part D prescription drug plan offers flexibility, nationwide access, and consistent coverage, making it an excellent choice for frequent travelers. Unlike Medicare Advantage plans, which are often geographically limited and depend on specific provider networks, Original Medicare with Part D ensures you can access care and prescriptions anywhere in the United States without restrictions.
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.
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 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 doctor recommended a bone density test. Is this considered preventive care under Medicare?
Yes, bone density screenings are considered preventive under Medicare Part B. They are typically covered every 24 months, however they can be approved more frequently if medically necessary.
Will Medicare cover everything my current employer plan does?
In general, most people on Medicare who receive employer health insurance will delay Medicare Part B enrollment. In this case Medicare Part A (in-patient services) is billed first. I would contact your employer health insurance plan to find out what your cost sharing would be for specific services.
I changed my plan during Open Enrollment and now I can't see my regular specialist. Isn't this what the whole review period is supposed to prevent?
The agent should have checked all of her doctors before they switched their policy. The client should of been aware of all of the benefits the new policy afforded her.
I thought I was covered during my snowbird months in Florida, but apparently not. What kind of plan do I actually need for that?
You actually have several options. Sounds like you have a HMO Advantage plan where you live. One option would be to stay on original Medicare with a supplemental plan. That would allow you access to any provider that accepts Medicare across the country. Another option would be a PPO Medicare Advantage plan if its available in you area. Several national carriers have network providers across the nation and would also provide coverage out of network.
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.
Why are hospitals not taking Medicare Advantage plans?
Hospitals negotiate with insurance companies and plans for payments. Depending on the plan's payment structure, a hospital (or any care provider) makes a business decision to accept the plan(s). Hospitals generally sign multi-year agreements with the insurance carriers.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 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.
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 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.
Should Medicare cover dental, vision, and hearing, or would that just make it more expensive for everyone?
If Medicare covered dental, vision and hearing it would increase the cost to tax payers no doubt. These services are provided by independent practices so it is most cost effective for them to be offered through private companies such as Humana, Aetna, Manhattan life etc….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.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.
Are all types of blood tests covered by Medicare?
No, not all types of blood tests are covered by Medicare. What is covered is medically necessary diagnostic blood tests which are ordered by a physician, but it may not cover routine or preventative blood work that is not medically justified.
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.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 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 just moved from New York to Florida and have Original Medicare with a New York Medigap plan. Do I need to change my coverage?
No, you will simply be re-calculated at the Florida rate. You may however, want to look at the Medicare Advantage plans in Florida as they are some of the most cost effective Medicare Advantage plans in the nation.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.
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 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'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.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.My Medicare Advantage plan advertised dental coverage, but it barely covers anything. Is this normal?
While many Advantage plans vary between networks and carriers, it's important to note that some can offer substantial coverage, and I’ve seen some reaching up to $1,700 per year for dental services. The type of coverage depends on whether it’s root canals or plain fillings, and that needs to be considered. However, it's essential to recognize that these plans may not be as comprehensive as standalone dental plans. Verify that your dental clinic is within the plan’s PPO or HMO network to maximize your benefits. This ensures you receive maximum benefits.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 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.
Can you explain what "creditable coverage" means and when it applies?
Credible coverage refers to health insurance that is considered as good as or better than Medicare, particularly for part B and part D. It’s most commonly relevant when someone is delaying Medicare because they’re still working and have an employer sponsored coverage. As long as that coverage is deemed credible, you can delay enrolling in Medicare without facing late enrollment penalties. When you do retire or lose that coverage, you’ll get a special enrollment period to sign up for Medicare without penalty
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.
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.
Medicare Plan Solutions serving NY & CT offering multicarrier plans • Poughkeepsie, NY
How does Medicare handle coverage for experimental treatments or clinical trials?
Routine services that would normally be covered under Medicare may be covered for participation in a clinical trial. But, clinical trial services and experimental treatment will not be covered. Any covered services would most likely be subject to prior approval. Likewise, your OOP responsibility would apply for covered services. Your provider should work with Medicare or other Medicare plan coverage carrier regarding specific criteria to actually participate. I also recommend the patient discuss with a carrier nurse to determine any patient responsibilities.
What's the deal with Medicare covering medical equipment like wheelchairs- do I need a special approval?
Most items that are covered under durable medical equipment by Medicare Will have a 20% copay to the member. Certain items such as a wheelchair with customizations may require a doctor's prescription and others, for example a shower chair, would not require a prescription. If you are enrolled in a Medicare Advantage plan you will want to check with the plan to ensure that you are using an in-network supplier to keep your cost at the lowest possible rate. And oftentimes places like senior centers will have received donations for things like transport chairs, walkers, shower chairs that you can borrow.
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.
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 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
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!
I'm worried about the 'donut hole' in my Part D plan. How do I manage my medication costs once I enter it?
The doughnut hole was eliminated in 2005 by the Inflation Reduction Act. The maxumum out of poket is now $2000. After you reach the $2000 limit your covered Medication will be a zero cost share. Also, you can request to make monthly payments on the $2000.
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.
What do seniors often misunderstand about Medicare's coverage for long-term care?
Some seniors think that Original Medicare covers all aspects of post hospital care. That is not the case. Original Medicare only covers "Skilled Nursing Care" and only for a certain period of time. Occupational and speech therapy is post-hospital care most people need but is only covered under Long-Term and Short-Term care plans.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.
Do I need a Hospital Indemnity Plan if I have Medicare Advantage? What if I am hospitalized twice in the same year?
A hospital indemnity plan to work with your Medicare Advantage plan is a good idea. Your Medicare Advantage plan will have daily copays (or at least per-stay copays) and the hospital indemnity plan can pay those for you. Most policies will pay more than once in a year as long as you have been out of the hospital for a set amount of days (differs per policy) before needing to go back in the hospital. Hospital indemnity policy premiums are usually inexpensive.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 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.
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.
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.
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?
There are many factors to consider when choosing your plan: network available in your geography, accessibility of providers & current health conditions. It’s not as easy to evaluate a plan based off premium unload. One needs to evaluate the big picture when choosing a plan.
Are home modifications (like stairlifts) ever covered by Medicare for safety reasons?
That's an interesting question. I just had this come up recently. With typical DME, Durable Medicare Equipment, like wheelchairs, hospital beds, etc., is usually covered under Medicare Part B. Stair lifts, in particular, would fall under Part A coverage and are generally not covered under Medicare. There is an actual exclusion for that type of Home Modification need.
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 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.
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'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?
That’s a great question, and one we hear a lot. Even though you’ve paid into Medicare through payroll taxes, that mainly covers Part A, which is hospital insurance—not everything. Part B, which covers outpatient care like specialist visits, has its own monthly premium and usually only covers 80% of the cost after you meet the deductible. That means you’re responsible for the remaining 20%, and there’s no out-of-pocket max unless you have additional coverage. This is where a Medicare Advantage or Supplement plan can help reduce or cap those costs. It’s frustrating, but you're not alone—Medicare can feel like a maze, and that's why it's worth reviewing your options to see what might lower your expenses moving forward.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.
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'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.
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 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.
I live in a rural area with limited specialists and am interested in telehealth options. How does Medicare cover virtual visits for someone in my location?
Original Medicare does cover telehealth visits and I will cut and paste information regarding telehealth visits as it relates to original Medicare hereHowever…
I want to bring to your attention the importance of comparing original Medicare, Medicare Supplement or Medigap and then Medicare Advantage plans, if you live in a rural area and need to access telehealth options.
Original Medicare, as mentioned above, does include telehealth, however it is limited in its scope, therefore because Medigap or Medicare Supplements simply work WITH Original Medicare…Medicare supplements or Medigap policies are also limited in their scope.
You can think about Medigap or Medicare Supplement and original Medicare like puzzle pieces. They work together, so if original Medicare cover something, Medicare supplement is required to come in and pick up what original Medicare does not cover at whatever benefit level you have on your plan.
Medicare advantage plans, however, provide enhanced benefits for telehealth so…oddly…if you’re living in a rural area, a Medicare advantage plan may offer you more options for telehealth that you would otherwise not have access to if you were simply on original Medicare and Medigap.
The reason I say “oddly” is because Medigap and original Medicare are often said to give you the most freedom and flexibility however, where you live and the network access that you have has a larger impact on the concept of freedom and flexibility as it relates to telehealth in this case.
This is why it’s so important to work with a broker because your broker can take a look at, not only, what is the “best option” for most people, but what really is the “best option for you.”
I hope you guys are having a great experience with your Medicare broker and if you’re not simply reach out!
I'm considering a smartwatch that monitors my heart rhythm for atrial fibrillation. Will Medicare help cover this type of wearable technology?
No, Original Medicare Parts ( A and B) do not cover Fitness Smartwatches that track heart rhythm or other vitals. Also Original Medicare does not cover Medical Alert Devices. If you are interested in getting either and having it covered by Insurance, some Medicare Advantage Plans offer coverage for these devices.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 physicalI want to get a shingles vaccine. Will Medicare cover this preventive service?
The Shingles vaccine is covered by your Part D Prescription plan. It is not covered by Part A or B. Medicare Part D covers all the recommended vaccines by the Advisory Committee on Immunization Practices (ACIP). This includes Shingles, RSV, whooping cough, etc. The plan will not charge you a copayment or credit towards a deductible for doing so.
My doctor wants me to get several preventive screenings. Will Medicare cover all of these at once?
There is a long list of preventive screenings that are covered by Medicare, including an annual Wellness visit.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.
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?
I will assume that you have power of attorney.First, you will need to understand the details of your father's prescription drug insurance (Part D) and the types(tier) and numbers of medications he is taking.
Next, you will need to confirm where the bill came from and contact the insurance company to find out if the claim is valid.
(I also recommend making a bullet point list.)
Finally, many insurance companies allow you to check the medication status online.
We recommend that you speak to your agent for more information.
Does Medicare pay for telehealth visits with specialists, or is it limited to primary care?
Yes many do. It’s important to know the limitations involved for your specific plan, so be sure to ask questions and check those situations before you make a choice on your plan if that’s an important issue for you.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 share
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?
I am assuming you are on Original Medicare Part B and not an Advantage plan.Yes, you have to meet your Part B deductible then you would have copayments for those services. The deductible this year is $257.
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'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 got Medigap Plan C, and I'm curious if my recent bloodwork is included or if I need to budget for extra costs.
If you’ve got Medigap Plan C, that’s actually one of the more solid plans. Since it works alongside Original Medicare, most of the time your bloodwork, if it’s medically necessary and ordered by your doctor should be covered by Medicare Part B, and then Plan C usually picks up the leftover costs like the deductible and coinsurance. So chances are, you’re not paying much, if anything. But it’s always good to double-check with your provider just in case something’s considered non-routine.
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.
Do I need extra protection like Critical Illness Insurance if I am on Medicare?
Critical illness, heart attack, stroke and cancer plans are optional indemnity plans that can be purchased separately. The plans pay you directly upon a certain diagnosis and are designed to cover non medical and out of pocket costs such as travel, lodging, missed time from work, experimental, treatments, etc. In short, you receive a cash payout that can be used at your discretion regardless of the type of medical coverage because there is no coordination of benefits with insurance companies.Does Medicare cover nutrition counseling for high cholesterol?
Yes it does.It covers it through a program called Medicare Nutritional Therapy Services.
Medicare Part B (Medical Insurance) covers certain doctors’ services, outpatient care, medical supplies, and preventive services.
If you have diabetes or kidney disease, or you’ve had a kidney transplant in the last 36 months, you qualify got this service and a doctor must refer you for services.
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 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 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.
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.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.I'm confused about preventive services under Medicare. Which screenings are actually free?
When it comes to Medicare, with Medicare Part A and B and the additional purchase of a Medicare supplement, or some call it Medigap, you can receive several preventive screenings and services at no cost. Diabetes, colon cancer, depression, hepatitis B, hepatitis C, HIV, cholesterol, and mammograms can all be covered without cost, if you have a Medicare supplement plan added to your traditional Medicare Part A and B.
I use several prescription apps and digital therapeutics for my chronic conditions. Does Medicare provide any coverage for digital health tools in cases like mine?
Medicare’s coverage for prescription apps and digital therapeutics (DTx) is limited but evolving, particularly for chronic conditions. Original Medicare (Parts A and B) typically does not cover DTx, as these tools often fall outside defined benefit categories. However, recent developments show some progress; so the answer would depend on what your currently using.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?
There can be a wide variety of answers to this question due to the various symptoms that folks can have. There are tools that can be used to "remotely" signal to an outside location that your heart is working properly (or not). You will be beholden to your cardiologist who is your expert and will write up "A PLAN OF CARE" specifically for you. It might entail a number of hours a day where the doctor feels that a registered nurse ought to see you daily or every other day, depending upon the cardiologist's discretion. The other side of this coin is that I can only presume that an operation to remedy your dilemma is out of the question. It can sometimes have a lot to do with which plan you picked up at age 65 between a Medigap or Supplement vs. a Med. Advantage plan both of which demonstrate differing benefits.I've heard about new AI-powered diagnostic tools for early disease detection. Does Medicare cover any of these cutting-edge technologies?
Yes, Medicare is increasingly covering AI diagnostic tools and services. AI is becoming a major player in all aspects of our lives and continues to grow in knowledge every day. It is being used to help diagnose people’s healthcare problems. However, it’s in its early stage and still needs to have the oversight of humans' approval before it can be accepted as a proper diagnosis.
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.
What's the likelihood of Medicare covering gene therapy as it becomes more common?
Yes - I am sure the likelihood is good of coverage to become more common.Medicare sometimes offers coverage for certain high cost treatments through specialized programs.
Medicare is likely to expand coverage for gene therapy as more evidence supporting its benefits and effectiveness emerges and as the treatments become more common and potentially more affordable.
Also have your Doctor submit an authorization for treatment to confirm coverages.
How might climate change-related health issues (like heat stroke) influence Medicare policies?
In my 25 years working with Medicare, climate change-related health issues like heat stroke have never come up in discussions or policy updates—not once. Honestly, it’s not something I’ve ever thought about either, but I’d assume it wouldn’t shift Medicare coverage much since conditions tied to it are already baked into what’s covered. Any impact would likely stay minor, handled within existing frameworks.What role might private insurers play if Medicare expands to cover more preventive care?
Medicare already provides a pretty significant list of preventative service covered under Medicare. If there is a plan you are looking at in specific, refer to your explanation of benefits for reference to specific preventative services you would like to see or know are covered.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
Coverage (132) Advice for Seniors (107) The Medicare System (80) Medicare Advantage (68) New To Medicare (48) Agent Interview (42) Medicare Part D (42) Prescription Drug (38) Medicare Part B (37) Medicare Supplement (29) Enrollment Periods (19) Medicare Part A (16) Turning 65 (13) Eligibility (13) Social Security (9) Retirement (8) Advice for Caretakers (6) Life Insurance (2) Medicare (1) Medicare Basics (1) Medicare FAQ (1)Have a Medicare Question of Your Own?
Submit your question to our nationwide community of licensed Medicare agents.
We'll only use your email to notify you when a licensed Medicare agent answers your question.