Medicare Questions & Answers: Medicare Advantage
Medicare Advantage Q&A
Showing 133 questions
Are Medicare Advantage plans really "free," or is that just clever marketing?
You've heard that "there's no such thing as a free lunch." Well, the same is true of Medicare Advantage plans.While it's true that there are Medicare Advantage plans that cost $0 in premium, they are not 'free' for a variety of reasons:
1. In order to qualify for a Medicare Advantage plan, you must have both Medicare Part A and Medicare Part B. There is a premium for Part B that must be paid every month.
2. You accept the terms and conditions of the Medicare Advantage plan that you choose, and that includes copayments and an out-of-pocket maximum for the services you receive. The fees you pay could add-up to thousands of dollars each year. While Medicare Advantage plans must be at least as good as Original Medicare, there will certainly be a cost to receiving medical care under Medicare Advantage.
3. Your Medicare Advantage plan is being paid by Medicare. Because they have taken-over responsibility for your medical needs, Medicare pays them a portion of what they expected to pay for your claims. The Medicare Advantage plan then decides how to spend that money in benefits. As the Medicare budget changes every year, so does the Medicare Advantage plan. It is important to review the changes in your Medicare Advantage plan every year.
4. You may end-up benefiting from Medicare Advantage by paying a little more for your medical claims, while receiving "extra" benefits like dental, vision, hearing, fitness, prescription drug and over-the-counter drug benefits at little to no cost. But in a year where you have a lot of expensive medical treatment, you could pay a lot more out of your pocket.
Is Original Medicare or Medicare Advantage better? Why do you recommend one over the other?
There is no single "better" option between Original Medicare & Medicare Advantage; the best choice depends on individual needs & preferences. Original Medicare offers broader access to providers & no network restrictions, while Medicare Advantage plans can provide additional benefits, lower costs, & potentially more coordinated care.Original Medicare:
Pros:
Access to any doctor or specialist who accepts Medicare nationwide.
No need for prior authorization for most services.
Ability to add a Medigap policy to supplement coverage & reduce out-of-pocket costs.
No network restrictions.
Cons:
May have higher out-of-pocket costs without a Medigap policy.
Does not include prescription drug coverage, requiring a separate Part D plan.
Does not cover additional benefits like vision, dental, or hearing.
Medicare Advantage:
Pros:
Often includes prescription drug coverage (Part D).
May include additional benefits like vision, dental, & hearing coverage.
May have lower copayments for some services.
May have an out-of-pocket maximum, limiting potential costs.
May offer more coordinated care and a primary care physician as a gatekeeper.
Cons:
May limit choices to a network of doctors & hospitals.
May require prior authorization for certain services.
Additional benefits & costs can vary significantly between plans.
Out-of-network care may be limited or more expensive.
Recommendation:
Choose Original Medicare if: You prioritize broad access to providers, don't need additional benefits like vision or dental, & are comfortable managing your own out-of-pocket costs (potentially with a Medigap policy).
Choose Medicare Advantage if: You prefer the convenience of a single plan that includes prescription drug coverage & additional benefits, are comfortable with network restrictions, & want to limit potential out-of-pocket costs.
Ultimately, the best choice depends on your individual health status, financial situation, & preferences for managing your healthcare.
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?
Here’s how you and your mom can check if her doctors are covered before switching:Step 1: Get a List of Her Current Providers
Write down every primary care doctor, specialist, hospital, and clinic she wants to keep.
Include her pharmacy too, since some MA plans restrict those.
Step 2: Check Each Plan’s Provider Directory
Every Medicare Advantage plan has an online provider search tool.
Go to the insurance company’s website, search by doctor’s name or facility, and confirm they’re “in-network.”
Call the doctor’s office directly and ask: “Do you accept [Plan Name Medicare Advantage] for the coming year?” (sometimes the websites are outdated).
Step 3: Check Prescription Coverage (Important!)
Use Medicare’s Plan Finder tool at Medicare.gov
to enter her medications.
This shows which plans cover them, and at what cost.
Step 4: Compare Out-of-Network Rules
Some MA plans are HMO (only in-network, very restrictive).
Others are PPO (can see out-of-network doctors, but at higher cost).
If her doctors aren’t in-network, she could face much higher bills — or be unable to see them at all.
Step 5: Talk to a Licensed Medicare Agent
An agent can screen all the local Advantage plans at once, instead of you checking each one individually.
They’ll tell you up front if a doctor or hospital drops out of a plan (which sometimes happens mid-year).
Key Caution:
Once she switches to Medicare Advantage, if she later wants to go back to Original Medicare with a Medigap supplement, she may face medical underwriting and be denied supplemental coverage in most states (unless she qualifies for a special trial right).
My advice: Confirm her doctors and meds before signing anything. Don’t rely only on what friends say, because the best plan for one person may not fit another.
What is the biggest disadvantage of Medicare Advantage?
At MedWise Trust, we are not promoters of the Advantage plans. They do work for about 30% of our clients. The biggest disadvantage of Advantage plans is the limited provider network and the potential for higher out-of-pocket costs. We advise that only our healthy clients choose this option. For people who need a lot of care or have costly healthcare needs we explain the benefits of Medigap plans. 60% of our clients choose Medicare supplements.Why?
1. Limited Network of Doctors & Hospitals
Unlike Original Medicare, seeing any doctor or specialist that accepts Medicare nationwide, Medicare Advantage plans (HMOs and PPOs) want you to use a network of approved providers. Some hospital networks do not accept them at all; Scripps Hospital in San Diego and the Mayo Clinic are just two examples of networks that do not accept Advantage plans.
If you can go out-of-network, you pay more. Some services may not be covered at all. (HMOs).
2. Potential for Higher Out-of-Pocket Costs
While MA plans often have lower monthly premiums, they can come with higher copays or coinsurance for certain services, especially: Out-of-pocket maximums. Hospital stays, specialist visits, and durable medical equipment all cost more and have limits
3. If you have chronic conditions or need a lot of care, these costs can add up quickly, possibly making the plan more expensive than Original Medicare + a Medigap plan.
4. Prior Authorization Requirements
Many MA plans require prior authorization for services like MRIs, rehab, home health care, and even some medications. This can delay care and cause stress if approvals are slow or denied.
Why do some agents push Medicare Advantage plans over Medigap-should I be skeptical?
There are 3 potential reasons that an agent might do this;1 - Medicare is easier to sell than a Medicare supplement when it comes to talking points. They are often $0 plans that offer additional benefits, whereas Medigap plans have additional premiums and no extra benefits. Advantage plans may even reduce your part B premium. So, on paper, they sound amazing and are easier to get someone to say yes to.
2 - Compensation for Medicare Advantage plans is higher than for Medigap plans. Unfortunately, there are agents who sell plans based on their best interest and not the client's.
3 - They may not be contracted to sell Medigap plans.
Generally, agents should take a neutral standpoint. They should explain the pros and cons of all coverage types and help the client choose what is best for them and their situation. Any agent who pushes one specific plan or coverage is usually doing a disservice to the client.
Can I switch from a Medicare Advantage plan to a Supplemental/Medigap plan during the Annual Enrollment Period without answering health questions?
Maybe. How long did you have a Medicare Advantage plan?If you are still in your first year of Medicare Advantage coverage and you previously had a Medicare Supplement plan that you dropped to join the Medicare Advantage plan, you may exercise your 'Trial Right' Special Enrollment Period to return to your Medicare Supplement plan with no medical questions. If that plan is no longer available, you may choose another Medicare Supplement insurance company and enroll without Medical Underwriting, within certain guidelines.
If you enrolled directly into a Medicare Advantage plan during your Initial Enrollment Period and are leaving that plan within the first 12-months of coverage, you may also choose to return to Original Medicare and enroll with a Medicare Supplement plan without Medical Underwriting, again, subject to certain guidelines.
This process can be a bit tricky because you must first drop the Medicare Advantage plan and return to Original Medicare before you may enroll for a Medicare Supplement plan, and this can take some time. The Annual Enrollment Period is from October 15 - December 7 each year, and it is a very busy time of year for Social Security and Medicare, as most Medicare beneficiaries need to review and make changes to their plans during that time of year. It is possible that you could leave your Medicare Advantage plan and go back to Original Medicare only to have your Special Enrollment denied by the insurance company and find yourself without a Supplement plan while also outside of the Annual Enrollment Period, so also unable to re-enroll in your Medicare Advantage plan. If you want to do this, be prepared to start the process in October to allow enough time for the disenrollment and re-enrollment. You do not want to wait until the end of November or beginning of December to start this process.
Can I keep seeing my current doctors if I switch to a Medicare Advantage plan, or do I have to find new ones?
Whether you can keep seeing your current doctors after switching to a Medicare Advantage plan depends on the plan’s network. Most Medicare Advantage plans, like HMOs or PPOs, have a network of doctors and hospitals you must use to get the lowest costs. If your doctors are in the plan’s network, you can likely continue seeing them. However, if they’re out-of-network, you may face higher costs or need to switch doctors, especially with HMO plans that typically require in-network care except for emergencies. PPO plans offer more flexibility for out-of-network providers, but at a higher cost. Some plans, like Private Fee-for-Service (PFFS), allow you to see any Medicare-approved doctor who accepts the plan’s terms, but not all providers do.To ensure you can keep your doctors, check the plan’s provider directory on their website or call the plan directly to confirm your doctors’ participation. You can also contact your doctors’ offices to verify if they accept the specific Medicare Advantage plan you’re considering. Always review the plan’s network rules before enrolling to avoid unexpected costs or changes in care.
My neighbor says I'm crazy for paying for a Medigap plan when Medicare Advantage is "free." What should I tell him?
When choosing between a Medicare Advantage Plan and a Medicare Supplement Plan (Medigap), there are no right or wrong answers. The best choice depends on each individual's financial and health needs.Medicare Advantage Plans (also known as Part C) replace Original Medicare (Part A and Part B). Many of these plans offer additional benefits, such as coverage for prescription drugs, dental, vision, and hearing services. While some Medicare Advantage Plans have no extra monthly premium, individuals must continue to pay their Part B premium, which is $185 in 2025. These plans also feature a maximum out-of-pocket limit, which helps protect you from high costs if you are hospitalized or require expensive medical procedures. Most Medicare Advantage Plans are available as either PPOs (Preferred Provider Organizations) or HMOs (Health Maintenance Organizations). If you choose a Medicare Advantage Plan, you will need to use in-network providers. Be aware that there are copayments and coinsurance costs associated with these plans.
Medicare Supplements (or Medigap plans) work alongside Original Medicare (Parts A and B). Original Medicare typically covers 80% of medical expenses, while a Medicare Supplement plan covers the remaining 20%. When you choose a Medigap plan, you still need to pay your monthly Part B premium of $185 (in 2025), in addition to the monthly premium for the Medicare Supplement plan. Although the total of these premiums can add up, the only out-of-pocket expense is the one-time Part B deductible of $257 (for 2025). All other copayments and coinsurance are covered by your Medicare Supplement plan.
In summary:
- A Medicare Advantage Plan generally costs less each month, but you will incur copayments or coinsurance whenever you visit a doctor or undergo a procedure. This means you are paying for care as you receive it.
- A Medicare Supplement Plan has a higher monthly premium, but your medical expenses are known. This means you are paying for care in advance.
What's the trade-off between a Medicare Advantage PPO and HMO when it comes to flexibility?
The differences between PPO's and HMO's are considerable. Both have advantages and disadvantages:Medicare Advantage PPO – More Flexibility
• See out-of-network providers: You can see doctors and specialists outside the plan’s network without a referral, though it will usually cost more than staying in-network.
• No need for referrals: You do not need a referral to see a specialist.
• Good for frequent travelers: More ideal if you travel often or split time between states/seasons, as you have coverage outside of your primary area (at higher cost).
• Higher premiums and/or out-of-pocket costs: You typically pay more for the added flexibility. It's also important to note that additional benefits such as dental are often richer with HMO's.
Medicare Advantage HMO – Less Flexibility, Lower Cost
• Must use network providers: You must get care from in-network doctors and facilities (except for emergencies or urgent care).
• Referrals required: You usually (but not always) need a referral from your primary care doctor to see a specialist.
• Lower premiums and copays: These plans generally cost less out of pocket, which can be a big draw for those who stay local.
• Often greater ancillary benefits such as dental, transportation, etc.
• Limited travel coverage: Not ideal if you travel a lot or live in multiple states seasonally.
In short, the important thing is to match your priorities with the plan. Please don't hesitate to contact me with any questions or need for assistance!
I signed up for a Medicare Advantage HMO, and I'm wondering if I can see a cardiologist out of network without paying everything myself.
Short answer: probably not — HMOs are the most restrictive plan type for out-of-network care.Here’s the breakdown:
How HMO out-of-network rules typically work:
In most MA HMOs, out-of-network care is simply not covered except in two situations:
• True emergencies (stabilization care is always covered regardless of network)
• Urgent care when you’re temporarily outside your plan’s service area
Outside those two exceptions, if you see an out-of-network cardiologist, you’re typically paying 100% out of pocket.
Your options to see a cardiologist:
1. Ask your PCP for an in-network referral — HMOs require this anyway. Your PCP coordinates specialist access within the network.
2. Check if your plan has a “cardiologist gap” — if no in-network cardiologist is available within a reasonable distance, your plan may be required to authorize out-of-network care at in-network cost-sharing. This is called a network adequacy requirement.
3. Request prior authorization for out-of-network care — in rare cases plans approve it when no in-network specialist is available.
4. Consider switching plans — if ongoing specialist access is a priority, a PPO gives you out-of-network flexibility (at higher cost-sharing, but not 100%). You’d need to wait for the MA Open Enrollment Period (Jan 1–Mar 31) or AEP in the fall.
Practical first step:
Call the Member Services number on your plan card and ask specifically: “
My kids keep telling me to get a Medicare Advantage plan, but my friends say stick with Original Medicare. Who should I listen to?
Everyone’s situation is different so to speak exactly as to your individual situation is hard to do.Generally, if you have the means to do so, and afford a Supplemental carrier plan, there is no better coverage then Original Medicare with a top Supplement offered in your state. This allows you to control your health, and have access to the best doctors, hospitals, facilities, and professionals within the medical community anywhere in the country at any time. For that you will have your Part A, B (which is $185/mo. and can be paid through your SSI) and the premium for your Supplement. You will also have a Part D Prescription plan that can be a $0-180 Premium per month. For the G plan here in Florida (the best plan) you are looking on average between $200-$230/ month. Unless it is a concierge doctor, 98% of Doctors accept this payment across the country.
For MA plans, you will have either a PPO, HMO, or PFFS plan, and will be limited as to your choices as you will generally have to stay in their networks. Your major specialty hospitals will not accept MA plans - examples: John’s Hopkins, Mayo Clinic, Cleveland Clinic, etc. Most plans require you to pick up the Part B still, and you may still have Co-pays, Co-Insurance, and deductibles. You will also have a MOOP and then the policy can apply. So be careful here. They may offer “gifts” and “freebies”, which make it front loaded for benefits, but where you really may need them is the backend, and we can’t be sure when that is for any of us!
Remember: Price is what you pay, Value is what you get, and Cost is what it is when paid the wrong price to get the wrong value! - so be careful as this is the ONLY TIME you will choose with no Underwriting involvement, and you can be sure that your health with age cannot ultimately improve, but have more challenges! Good luck!!!
Is it better to get Medicare Part D or Medicare Advantage?
It depends on your priorities — they serve different purposes, and sometimes people even combine coverage strategies. Here’s the short comparison:Medicare Part D (Prescription Drug Plan)
Purpose: Covers medications only.
Works with Original Medicare (Parts A & B).
Can be added to Original Medicare at any time (with enrollment periods).
Pros:
Keeps Original Medicare freedom to see any doctor or hospital that accepts Medicare
Multiple plan options for prescriptions
Cons:
Does not cover extra benefits like dental, vision, or hearing
You still pay deductibles, coinsurance, and premiums for Part A/B
Medicare Advantage (Part C)
Purpose: Combines Part A, Part B, and usually Part D into one plan.
Often includes extra benefits like dental, vision, hearing, fitness programs, and sometimes OTC allowances.
Pros:
One plan, one card, simpler management
Extra perks not in Original Medicare
Cons:
Usually network restrictions (HMO/PPO rules)
Travel and specialist access can be limited
Out-of-pocket costs can vary widely
Bottom line
If you value provider choice and broad access: Original Medicare + Part D + Medigap may be better.
If you want lower premiums and extra benefits: Medicare Advantage may make sense — but check the networks and coverage for your doctors and prescriptions carefully.
If I move to a rural area, how might that limit my Medicare Advantage plan options?
I work with hundreds of Medicare Advantage members in rural areas, so I've seen pretty much every limitation there is to be had. Assuming there are Medicare Advantage options in your new area, there will most likely be few of them. I find that the most limiting factor will often be the plans' network and access to services. Medical, dental, and vision providers are often slower to join Medicare Advantage plan networks in rural areas, particularly if they are new to the area.If you currently have a Medicare Advantage plan and that plan isn't offered in the area you're moving to, you will have the option of purchasing a Medicare supplement (Medigap) plan without having to go through underwriting. If your new area doesn't have Medicare Advantage options, or you would have enrolled in a Medigap plan earlier but couldn't have passed the underwriting process, this could be a great opportunity.
I recommend working with an independent agent that offers both Medicare Advantage and Medigap plans well in advance of your move to help you weigh all of your options.
I picked a Medicare Advantage plan based on the low premium, but now I'm facing high copays. Did I make a mistake?
You did not necessarily make a mistake. Low-premium Medicare Advantage plans are common, but they operate as a "pay-as-you-go" system. They trade low monthly premiums for higher copays when you actually receive care. Here is what you need to know:Your Protection: Your plan likely has a mandatory Maximum Out-of-Pocket (MOOP) limit. Once you hit this cap, the plan covers 100% of your medical costs for the rest of the year.
When It Works: Low premiums save money if you rarely visit the doctor.
When It May Not Be a Good Fit: Frequent specialist visits, scans, or hospital stays can quickly outpace your premium savings.
How to Fix It:
You can switch to a plan with higher premiums but lower copays during the next Medicare Annual Enrollment Period (October 15 – December 7).
Or, if you are interested in a Medicare Supplement/Medigap Plan, you may have options for enrolling sooner.
I recommend you reach out to a local Medicare Broker to help you find a plan that works for your healthcare needs.
Should I keep original Medicare or go with an Part C, Medicare Advantage plan? What is better?
The difference between Medicare Supplement and Medicare Advantage plans. Many people think these things are the same. They're actually quite different. A Medicare Advantage plan is typically either an HMO or PPO type of plan where you have to worry about doctors and hospitals being in networks. They usually have a lower premium than a Medicare supplement. Depending on where you are, certain service areas have a zero premium plan, which does not cost you anything above and beyond what you would normally pay for just a part B premium. Medicare Advantage plans typically do include prescription drugs. They do have a maximum out-of-pocket, referred to as MOOP, of maximum $9,350. So that is your worst-case scenario. Even if something catastrophic were to happen, they won't give you some coverage, usually for dental, vision, and hearing. But it's usually not comprehensive, but more preventative. So for dental, things like checkups, cleanings, and sometimes they will offer a wider range to give you more comprehensive dental. The Medicare Advantage plans are locked in for one year, and you can only get the plans that are in your service area. With Medicare supplement, you will pay a higher premium, but you do get better coverage. You don't have to worry about networks. You can go to any doctor, any hospital that you want. Medicare supplements do not include prescription drugs, so you probably also want to get a standalone prescription drug plan. Medicare supplement will also not give you anything towards dental, vision, and hearing. But again, you can get a standalone dental, vision, and hearing plan. Medicare supplements can also be changed at any time throughout the year. Unlike Medicare Advantage and prescription drug plans that you're locked into for the year, and you can't change it till the end of the year for a January 1st effective date. The first time you get a Medicare supplement, you will get a guaranteed issue, so you don't have to answer health questions. But after that, in the future, if you want to change to a different plan or a different carrier, you will need to go through health underwriting and answer health questions. And there are no service areas that you have to worry about. So if you have any other questions, please feel welcome to give me a call. I am licensed in every state and DC.
What's your go-to strategy for helping someone decide between Medicare Advantage and Medigap?
Here is the updated response:My go-to approach is to start with a simple education session before ever talking about specific products. I literally pull out a piece of paper and walk through the basics so the person in front of me can see exactly how Medicare works, what the gaps are, and why those gaps matter. When people can look at it visually and follow along, the whole thing starts to make a lot more sense. From there I assess their full picture, including their budget, their health situation, how often they use their coverage, and which doctors and medications matter most to them. Honestly, if someone can afford a Medigap policy, that is usually my first preference because the freedom, predictability, and access it provides are hard to beat, especially as people get older and start using their coverage more frequently. But the reality is that the monthly premium for a supplement plus a standalone Part D plan is out of reach for some people, and putting someone in a plan they cannot comfortably afford does not serve them well. In those cases, the goal shifts to finding the best possible Medicare Advantage plan for their specific needs, making sure their doctors are in network, their medications are covered, and their out-of-pocket exposure is manageable. There is no one size fits all answer, and anyone who tells you otherwise is not giving you the full picture. The best plan is the one that fits your life and your budget, and that looks different for everyone.
How do you explain to clients that "zero-premium" doesn't mean "zero-cost" with Medicare Advantage?
Zero-premium sounds like ‘free Medicare’ — but it’s not zero-cost. It’s more like a cell phone plan with $0 monthly fee… until you start using data, minutes, or roaming.The honest breakdown:
✅ Zero premium = You pay $0 extra to the insurance company each month for the Medicare Advantage plan.
❌ You still pay your regular Medicare Part B premium — about $202.90 per month in 2026 for most people.
❌ When you actually use healthcare, you pay copays, coinsurance, and deductibles:
Doctor visits: often $20–$50 each
Hospital stays: hundreds or thousands before the plan kicks in fully
Prescriptions: copays that add up fast
Other services: tests, therapies, surgeries
Even with a generous plan, you could still face thousands of dollars in a bad health year — though most plans cap your maximum out-of-pocket (often $5,000–$9,000+).
Real-world example:
Last year I had a client with a $0 premium plan. He thought his heart procedure would cost almost nothing. Between the hospital copay, specialist visits, and rehab, he still paid over $4,000 out of pocket that year.
Bottom line:
Zero-premium plans can be great if you’re healthy and stay in-network. But they shift costs from monthly premiums to when you get care. That’s why we always look at your total estimated costs — not just the flashy promise of a $0 premium.
My Medicare Advantage plan covers dental, but I can't find a dentist who accepts it. Is this a common problem?
Yes, this is an common problem. Many seniors find that while their plan "includes" dental, the actual list of dentists who accept it is surprisingly small. This often happens because many dentists feel the reimbursement rates are too low, or they aren't part of the specific network your insurance uses.Here is the best advice to help you find a provider:
Search by the "Network Name," not just the Plan: Your insurance might be through one company, but they often use a third-party dental specialist like DentaQuest or Delta Dental. When calling a dentist, ask if they take that specific network name—they are much more likely to recognize it than your general Medicare Advantage plan name.
Use the Official "Find a Dentist" Tool: Don't rely on old paper booklets. Use the live online search tools from your insurer—whether you're with Aetna, Humana, or UnitedHealthcare—as these are updated more frequently.
Check for "Out-of-Network" Coverage: If your plan is a PPO, you might not be strictly limited to a list. You can often see any licensed dentist you like; you’ll just pay a bit more out of pocket while the plan still covers a portion of the bill.
Consider a Standalone or Discount Plan: If your current network is just too restrictive, you might look into a standalone dental plan or a "dental discount plan." Many local dentists prefer these because there is far less paperwork involved than with Medicare Advantage.
I chose Original Medicare to keep my doctors, but now I'm drowning in bills. Should I have gone with Advantage instead?
Choosing Original Medicare was not a mistake, but you missed a critical piece of the puzzle: a Medicare Supplement (Medigap) plan.Original Medicare (Parts A and B) is excellent for keeping your doctors, but it has no safety net. It only covers 80% of your outpatient bills, leaving you responsible for the remaining 20% out-of-pocket with no lifetime limit. If you face a serious medical issue, that 20% can easily lead to financial disaster.
Option 1: Add a Medigap (Medicare Supplement) Plan. This is the most direct fix if you want to keep your unlimited doctor access. Medigap plans are private insurance policies designed specifically to step in and pay that remaining 20% coinsurance for you.
The Primary Benefit: You keep 100% of your current doctors and can see any specialist in the country who accepts Medicare—no networks, no referrals, and no pre-authorizations.
The Cost Structure: You will pay a predictable monthly premium (usually between $120 and $250 a year, depending on your age and location). In exchange, plans like Plan G cover virtually all of your leftover medical bills, reducing your out-of-pocket medical expenses to almost zero
The Catch (Underwriting): Because you did not enroll in Medigap when you first started Part B, you may have passed your initial Medigap Open Enrollment Period. In most states (including New Jersey), private insurers are now allowed to look at your medical history and can deny you coverage or charge you more based on pre-existing conditions.
Option 2: Switch to a Medicare Advantage Plan
If you cannot pass medical underwriting for a Medigap plan, or if you cannot afford a monthly Medigap premium, switching to Medicare Advantage (Part C) is your alternative safety net. The Primary Benefit: These plans usually have $0 or very low monthly premiums, and they legally must include a Maximum Out-of-Pocket (MOOP) limit.
How can I verify if a Medicare Advantage plan's advertised benefits are legit?
Start by going directly to Medicare.gov and using their plan finder tool to look up the specific plan. Everything a Medicare Advantage plan offers has to be filed with CMS, so the official details will be there including premiums, copays, drug coverage, and extra benefits. Compare what you see on Medicare.gov with what the plan is advertising. You can also request the plan's Summary of Benefits and Evidence of Coverage documents, which spell out exactly what's covered and what's not. If something sounds too good to be true, like free groceries or extensive dental with no catches, dig into the fine print because those benefits often have limits, eligibility requirements, or only apply in certain situations. And if an agent is pushing a plan hard without answering your questions directly, that's a red flag. You can also call 1-800-MEDICARE to ask about a specific plan or report misleading advertising.
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?
This is one of the biggest frustrations I hear from people with PPO Medicare Advantage plans.A PPO does give you more flexibility than an HMO because you can go outside the network without needing referrals in many cases. But what many seniors don’t realize is that “out-of-network” does NOT mean “covered the same.”
In most PPO plans:
• In-network providers have lower copays and negotiated rates
• Out-of-network providers can charge significantly more
• Deductibles and coinsurance are often much higher outside the network
• Some doctors may not even agree to bill the plan directly
So yes — you technically have access to more doctors, but the financial exposure can become very expensive very quickly.
That’s why understanding the Maximum Out-of-Pocket (MOOP), coinsurance percentages, and provider contracts matters so much before choosing a plan.
For some people, a PPO makes perfect sense because of travel, specialist access, or provider preference. For others, the added costs end up outweighing the flexibility.
This is exactly why I always tell people:
Don’t just choose a plan based on the premium or a TV commercial. The real question is how the plan actually works when you need care.
I help seniors compare these details every day so they understand the tradeoffs before problems happen — always at no cost.
Chuck Winslow
US Marine Veteran 🇺🇸
Retirement & Legacy Planner
Contact me.
Can I show my Original Medicare Card instead of my Medicare Advantage card, if my provider doesn't take my advantage insurance?
No. If you’re enrolled in a Medicare Advantage (MA) plan, you must use your MA card, not your red, white, and blue Original Medicare card because your MA plan replaces Original Medicare for all your covered services.Showing your Original Medicare card won’t work because Medicare won’t pay the claim; your MA plan is legally responsible for your coverage. If a provider doesn’t accept your Medicare Advantage plan, you generally have three options:
1. See a provider who is in-network (or accepts your MA plan if it’s PPO).
2. Ask about out-of-network benefits, some MA PPOs cover them at a higher cost.
3. Pay out of pocket, which most people try to avoid.
The only time you can use your Original Medicare card is if you officially disenroll from your MA plan and return to Original Medicare during a valid enrollment period.
I have Original Medicare, and I'm wondering if I'd save more on my dental cleanings if I switched to a Medicare Advantage plan instead.
Most likely there’s a plan in your area that has some level of dental coverage. Some things to keep in mind:- some areas do not have any plans with dental coverage, and the amount of coverage and copays will differ significantly, so you’ll need to so some comparison shopping (of course an agent will help with that, but you can also go to Medicare.gov)
- we’ve had a few tough years, cost-wise, so many plans are pulling back on the ancillary coverage (Dental Vision and Hearing, or DVH). I personally don’t see that changing going into 2027. Still, many plans will cover cleanings even if they don’t provide comprehensive coeverage.
- You will need a valid election period to enroll in a MA plan. That usually means AEP from October 15-Dec 7 unless a special election period applies. Again, an agent can walk through some situations to see if that’s the case.
- You’ve (hopefully) got a Prescription Drug plan, and may be paying for it. If so, you may save money with an MAPD because it replaces the standalone drug plan and many have no premium. It depends on your service area as to what is available.
- if you go with an MAPD, your doctor selection will be limited to the plan’s network, or, if it’s a PPO, you’ll pay higher copays for doctors out of network.
- You can also pick up dental coverage separately and not change your medical coverage. Most agents have several options available for stand-alone dental coverage.
- if all you have is OM + a PD plan, you have some financial exposure since medicare has no out of pocket maximum, so I really do recommend either a Medigap plan or Medicare Advantage to help mitigate that risk.
I hope this helps!!
My Medicare Advantage plan listed my doctor, but now they say he's out of network. How is that even allowed?
Unfortunately, yes, this can be allowed.With Medicare Advantage plans, the doctor network is based on contracts between the insurance company and the doctor, medical group, or facility. Those contracts can change during the year. A doctor can leave the network, a medical group can stop participating, or the plan may update its network based on contract changes.
That is why a doctor may show as in-network when you enroll, but later show as out of network.
That does not mean it feels right, especially if you chose the plan specifically because that doctor was listed. But Medicare Advantage plans are not required to keep every doctor in the network for the full year.
The key question is what happened:
Was the doctor truly in-network when you enrolled?
Did the doctor or medical group leave the plan mid-year?
Or was the provider directory incorrect when you reviewed the plan?
The next step is to call both the insurance company and the doctor’s billing office and ask for the effective date of the network change. If the doctor was listed incorrectly, or if the network change creates a major access issue, then we can review whether there are any options available.
Important distinction: if the mistake came from the insurance company’s own provider directory, the special 2026 Plan Finder SEP may not apply. CMS says that particular SEP is only for people who relied on incorrect information from Plan Finder, not from a plan website. But the plan website error may still support a case-by-case SEP request through Medicare if the information was misleading or incorrect. Medicare.gov specifically says to call 1-800-MEDICARE if you think you have an exceptional circumstance.
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?
You’re asking the right question—hearing aid coverage is one of the most misunderstood Medicare Advantage benefits.Here’s how to figure it out step by step, without getting bounced around or sold something you don’t need.
Step 1: Check the Evidence of Coverage (EOC) — not the summary
Skip the glossy brochure. You want the Evidence of Coverage (EOC) for your exact plan and year.
How to find it:
Log into your plan’s member portal or
Google: “[Plan Name] Evidence of Coverage hearing aids”
Search inside the document for:
“Hearing aids”
“Audiology”
“Hearing services”
This tells you what’s actually covered.
Step 2: Look for these 5 key details
When you find the hearing section, check:
Is it hearing exams only, or actual hearing aids?
(Many plans only cover exams.)
Coverage amount
Examples:
“Up to $1,000 every 2 years”
“One hearing aid per ear every 3 years”
“Discount program only” (this is NOT true coverage)
Approved providers
Many plans require:
A specific vendor (like TruHearing, NationsHearing, HearUSA)
An in-network audiologist
Prior authorization required?
Often yes.
Brand or model limits
Some plans cap you at basic technology levels.
Step 3: Call the plan — but ask the right questions
When you call the number on the back of your card, ask exactly this:
“Can you tell me my hearing aid benefit, including dollar amount, frequency, required vendors, and whether prior authorization is needed?”
Ask them to:
Email or mail the benefit summary
Confirm whether your current audiologist is in-network
💡 Write down the date, name, and reference number of the call.
Step 4: Talk to your audiologist before buying anything
Your hearing provider can:
Verify benefits
Check vendor restrictions
Tell you if your plan’s benefit will actually apply
Many people lose coverage because they bought aids before confirming the plan rules.
One important reality check
Even with “coverage,” many Medicare Advantage plans:
Only partially pay for hearing aids
Li
Do Medicare Advantage plans really save seniors money in the long run? Why or why not?
It depends, and "in the long run" is really the key phrase in that question. I could ask you how well do you predict the future?For a lot of seniors — especially people who are generally healthy and don't see many specialists — Medicare Advantage genuinely does save money in a given year. Premiums are often low or $0, and you're getting dental, vision, and other extras bundled in that you'd otherwise pay for separately.
But that math can flip in a bad health year, because your maximum out-of-pocket cost resets every January, and that number has been climbing. The national median out-of-pocket cap on Medicare Advantage plans went from $5,400 in 2025 to $5,900 in 2026 — nearly a 10% jump in one year — and some plans allow as much as $9,250.
So the "long run" question really comes down to whether your health stays the same as it is today, and it rarely does. Someone who's healthy for five years and then has a rough sixth year with a hospital stay or a new diagnosis can end up paying more cumulatively on Medicare Advantage than they would have with a Supplement plan's steady, predictable premium the whole time.
Neither answer is universally correct — it depends on how much your health changes and how much certainty is worth to you. That's not a question you or anyone can answer, but it is one that I, or any excellent independent Medicare agent, will spend time with you to make the right decision.
Part A Inpatient Hospital deductible $1,676 but if I have Part C Advantage Plan, the hospital $350 copay per day 1-7 so how does this work?
If you have Original Medicare (Part A and Part B), you’d normally pay the Part A inpatient hospital deductible, which in 2025 is $1,676 for each benefit period. After that deductible is paid, Medicare covers most of the cost for your hospital stay.However, if you have a Medicare Advantage (Part C) plan, that plan replaces Original Medicare coverage. You do not pay the Part A deductible — instead, you follow your plan’s own cost-sharing rules.
For example:
If your Medicare Advantage plan says $350 copay per day for days 1–7, that means each day you’re in the hospital (up to 7 days), you pay $350 per day. After that, the plan usually covers 100% for the rest of your stay (days 8–90), depending on the plan’s terms.
So in short:
You don’t pay both the Part A deductible and the $350 per day.
The Part C plan’s copay schedule replaces Medicare’s deductible and coinsurance.
Always check your Evidence of Coverage (EOC) for your plan’s exact inpatient hospital costs.
My diabetes medication is super expensive, and I've heard horror stories about Part D not covering what people need. Should I go standalone Part D or get it through a Medicare Advantage plan?
Standalone Part D Plans:Flexibility: You can generally choose any pharmacy that participates in the plan, & you're not limited to a specific provider network.
Coverage: Part D plans cover a wide range of diabetes medications, including insulin & other oral medications.
Formulary: While Part D plans have formularies (lists of covered drugs), they may be more flexible than some Medicare Advantage plans.
Prior Authorization: Some Part D plans may require prior authorization for certain medications, but this is less common than in Medicare Advantage plans.
Cost: Part D plans can vary in price, so it's important to compare premiums & copays.
Special Considerations: The Inflation Reduction Act significantly reduced the cost of insulin, limiting out-of-pocket costs to $35 per month. If you have limited income & resources, you may be eligible for Extra Help to lower your drug costs. You can also explore patient assistance programs offered by pharmaceutical companies.
Medicare Advantage Plans (MA-PDs):
Comprehensive Coverage: MA-PDs typically offer all the benefits of Original Medicare (Parts A and B) plus drug coverage (Part D).
Provider Networks: MA-PDs often have specific provider networks, which may limit your choice of doctors & pharmacies.
Prior Authorization: Some MA-PDs may require prior authorization for certain medications, even if they are on the formulary.
Cost: MA-PDs can have lower premiums than standalone Part D plans, but copays & deductibles may vary.
Coordination of Care: MA-PDs may offer additional services like preventive care & chronic disease management, which can be helpful for people with diabetes.
Special Considerations: MA-PDs may have more strict rules about which medications are covered, & it's important to check the formulary. You may also need to obtain a prescription for any medications from your primary care physician. Some diabetes-related supplies like syringes, gauze & alcohol may also be covered by MA-PDs.
What's the best way to compare my current Medicare supplement plan to a Medicare advantage plan?
What's the difference between Medicare Supplement and Medicare Advantage plans? Many people think these things are the same, but they're actually quite different. A Medicare Advantage plan is typically either an HMO or PPO type of plan, where you have to worry about doctors and hospitals being in-network. They usually have a lower premium than a Medicare Supplement, and depending on where you're at, certain service areas have a zero premium plan that doesn't cost you anything above and beyond what you would normally pay for just the Part B premium.
Medicare Advantage plans typically include prescription drugs. They do have a maximum out-of-pocket, referred to as MOOP, of $9,350, so that is your worst-case scenario. Even if something catastrophic were to happen, they will give you some coverage, usually for dental, vision, and hearing, but it's typically not comprehensive—more preventative. For dental, things like checkups and cleanings are covered, and sometimes they will offer a rider to give you more comprehensive dental.
Medicare Advantage plans are locked in for one year, and you can only get the plans that are in your service area. A Medicare Supplement will have a higher premium, but you do get better coverage. You don't have to worry about networks; you can go to any doctor or hospital that you want. Medicare Supplements do not include prescription drugs, so you probably also want to get a standalone prescription drug plan. Medicare Supplements also won't give you anything towards dental, vision, and hearing, but again, you can get a standalone dental, vision, and hearing plan.
Medicare Supplements can be changed at any time throughout the year, unlike Medicare Advantage and prescription drug plans, which lock you in for the year and you can't change them until the end of the year for a January 1st effective date. The first time you get a Medicare Supplement, you will get a guaranteed issue, so you don't have to answer health questions. But after that, if you want to change to a different plan or a different carrier, you will need to go through health underwriting and answer health questions, and there are no service areas that you have to worry about.
I've been on my employer's health plan but am retiring soon. What should I consider when moving to Medicare?
Congrats on your upcoming retirement! Transitioning from an employer plan to Medicare can be smooth if you plan ahead. Here’s the key stuff to consider:1. Timing is critical
Your Initial Enrollment Period (IEP) for Medicare starts 3 months before your 65th birthday, includes the month of your birthday, and ends 3 months after.
Late enrollment penalties can apply if you miss your window.
Tip: If your employer coverage continues past 65 and has 20+ employees, you may qualify for a Special Enrollment Period (SEP) when you retire — no penalty.
2. Compare coverage and costs
Check what your employer plan covers vs. Medicare (doctor visits, prescriptions, hospital stays).
Look at premiums, deductibles, and out-of-pocket maximums for both Medicare and any supplemental coverage.
3. Part D for prescriptions
If your employer plan covers drugs, you may not need Part D immediately.
When you drop employer coverage, you can enroll in Part D during your SEP without penalty.
4. Consider Medigap or Medicare Advantage
Medigap (Supplement): Helps cover Part A/B out-of-pocket costs. Best for flexibility and freedom to choose doctors.
Medicare Advantage: Combines A/B + usually D, often with extra benefits like dental, vision, and hearing—but may have network restrictions.
5. Check provider networks
Make sure your doctors and preferred hospitals are in-network if you go with Medicare Advantage.
Medigap gives you freedom to see any Medicare provider.
6. Coordination of benefits
If you keep employer coverage while on Medicare, Medicare may be primary or secondary depending on your employer size.
Understanding this prevents unexpected bills.
7. Don’t rush—review all options
Compare Original Medicare + Part D + Medigap vs Medicare Advantage
Use the Medicare Plan Finder or consult a Medicare agent to find the best fit.
As a senior, what should I know about the differences between Original Medicare and Medicare Advantage before I choose?
Original Medicare + Medigap: Offers more freedom, nationwide access, predictable costs.You can see any doctor or hospital in the U.S. that accepts Medicare.
No networks. No referrals.
Medigap (Medicare Supplement) helps cover deductibles, copays, and coinsurance, giving you predictable, stable costs.
With Original Medicare + Medigap, you typically pay:
Part B premium
Medigap premium
A Part D drug plan
Optional dental, vision, and hearing coverage
This path offers the most cost predictability and nationwide access.
Medicare Advantage: Provides lower premiums, bundled benefits, along with network limits, and out of pocket (OOP) costs that are not stable nor predictable.
Medicare Advantage
Medicare Advantage is Medicare through a private plan.
Many plans have low or $0 premiums and include:
Drug coverage
Dental, vision, hearing
Fitness and other extras
Important to note is:
You must use the plan’s network
Some services require prior authorization
You pay copays, deductibles, and coinsurance as you use services
This path offers convenience and bundled benefits, but with network rules and pay‑as‑you‑go costs.
Both Medicare options are viable. Your choice depends on your needs, your budget, and your travel adventures.
What is the biggest disadvantage of the Medicare Advantage plans?
One of the biggest disadvantages of Medicare Advantage plans is that they often come with more restrictions on how you access care compared to Original Medicare.Most Medicare Advantage plans use provider networks (HMO or PPO structures), which means you may need to stay in-network to get the lowest costs. In some cases, you may also need referrals to see specialists. This can limit your flexibility if you want to see specific doctors or receive care while traveling.
Another important consideration is cost variability. While many plans advertise low or $0 premiums, you can still have copays, coinsurance, and out-of-pocket costs for services — and those costs can add up depending on your health needs. Even though there is an annual out-of-pocket maximum, it can still be several thousand dollars.
Prior authorization is another common challenge. Some services, treatments, or procedures may require approval from the insurance plan before they are covered, which can delay care.
Finally, coverage can change year to year. Benefits, networks, and drug formularies are reviewed annually, so a plan that works well one year may not stay the same the next.
The key takeaway is that Medicare Advantage can work very well for many people, but the trade-off is typically lower upfront costs in exchange for less flexibility and more plan-managed rules compared to Original Medicare with a Medigap plan.
I want to switch to Medicare Advantage this year. How do I do this?
That’s a great question. It's fantastic that you're looking into your options for the upcoming Annual Enrollment Period. Switching to a Medicare Advantage Plan (MAPD) can be a beneficial choice for many beneficiaries, as it often combines health coverage and prescription drug benefits in one plan.First, make sure you understand the difference between your plan and a Medicare Advantage plan, think about what you like and dislike about your current coverage. Are there specific doctors or medications you want to keep or change?
Next compare Available MAPD Plans: During AEP, which runs from October 15 to December 7, you can explore different MAPD options that are available in your area. Look for plans that cover your medications, have a good network of doctors, and benefits that you are interested in.
After that, use the Medicare Plan Finder on the official Medicare website to compare plans. Additionally, I can help guide you through available options and answer any questions.
Lastly, when you find a plan that fits your needs, you can enroll directly through the plan's website, by calling their customer service, or I can assist you with the enrollment process.
Remember, you have a one time safeguard, if you want to switch back to your Medicare Supplement plan, you can do so within a certain time frame.
If you have specific plans in mind or need assistance comparing options, feel free to ask!
Why is regular Medicare better than an advantage plan?
This is one of the biggest debates in Medicare, and the answer depends on your priorities. Many people choose Medicare Advantage because the low premiums and extra benefits (like dental or vision) sound attractive. But here’s why Original Medicare (“regular Medicare”) is often considered better by doctors, hospitals, and patient advocates:Reasons why Original Medicare is often preferred include: 1. Freedom to See Any Doctor Nationwide. With Original Medicare, you can see any doctor or hospital in the U.S. that takes Medicare, no networks, no referrals. With Medicare Advantage, you’re limited to the plan’s network, and going out-of-network can mean big bills or no coverage at all; 2. Guaranteed Coverage for Medically Necessary Care; Original Medicare covers medically necessary care as defined by federal law. Medicare Advantage plans can require prior authorization, meaning the plan must approve before you get care.
This can delay or deny treatments; 3. No “Surprise” Network Changes. Doctors and hospitals can leave an Advantage network anytime during the year. With Original Medicare, as long as the provider accepts Medicare, you’re covered; 4. Easier When Traveling or Moving; Original Medicare works anywhere in the U.S.
Medicare Advantage plans are local/regional, move or travel, and your plan may not cover you. 5. Predictability with Medigap
If you add a Medigap supplement, your out-of-pocket costs with Original Medicare can be very low and predictable. Advantage plans have lower premiums up front, but if you get really sick, you could face thousands in costs (up to $8,850 per year in 2025, not including drugs).
The tradeoff is that Medicare Advantage = lower monthly costs, extra perks, managed care (but with restrictions). Original Medicare = more freedom, broader coverage, stronger protections (but you’ll likely pay more monthly if you add Medigap + Part D). Many people who value choice of doctors and fewer hassles prefer Original Medicare.
Should there be stricter regulations on Medicare Advantage marketing and sales practices?
Yes—there is a strong case for stricter enforcement and, in some areas, tighter rules. CMS has already strengthened Medicare Advantage marketing rules, including limits on compensation structures that can steer agents toward certain plans and updated marketing requirements for third-party materials, which suggests regulators already saw real problems that needed correction. The main reason is that Medicare is complicated, and many beneficiaries are vulnerable to confusing or misleading sales tactics. KFF has documented beneficiary concerns about aggressive marketing and the difficulty people have understanding their options, especially during enrollment season. 
That said, the goal should not be to shut down legitimate education or ethical sales conversations. The better approach is stricter oversight of misleading ads, stronger disclosure requirements, clearer distinctions between educational events and sales events, and tougher penalties for brokers or organizations that misrepresent benefits, provider access, or plan costs.
My Medicare Advantage plan advertised dental coverage, but it barely covers anything. Is this normal?
Yes — unfortunately, this is very common with Medicare Advantage dental benefits. What you’re experiencing is something many people run into, and it’s not because you misunderstood — it’s how these plans are designed.Here’s why it happens and what you can do about it.
Why Medicare Advantage dental often feels disappointing
1. “Dental coverage” usually means limited preventive care
Most Medicare Advantage plans cover:
2 cleanings per year
X-rays and exams
But major services (crowns, root canals, dentures, implants) are often:
Not covered at all, or
Covered at very low annual maximums (commonly $500–$1,500)
2. Annual caps are very low
Unlike medical coverage, dental benefits usually have a hard dollar limit per year.
Once you hit it, you pay 100% of the remaining cost.
Example:
$1,000 annual dental max
Crown costs $1,200–$1,500
You pay most of it out of pocket
3. Waiting periods & exclusions
Many MA dental benefits:
Exclude pre-existing dental issues
Require waiting periods for major work
Do not cover implants at all
Ads rarely mention this.
4. Network restrictions
You often must:
Use specific dental networks
Choose from a limited list of dentists
Accept negotiated fees that still leave high out-of-pocket costs
Is this misleading advertising?
Not exactly — but it is marketing-friendly wording.
Plans are allowed to advertise “dental coverage” even if it’s:
Preventive only, or
A small allowance that doesn’t go far
This is why reviewing the Evidence of Coverage (EOC) matters — not just the summary or ad.
What you can do now
1. Review your plan’s dental max and coverage categories
Look for:
Preventive vs basic vs major
Annual maximum amount
Waiting periods
Implant coverage (if important to you)
I can help you interpret it if you want.
2. Consider switching plans at the right time
You may be able to change plans during:
Annual Enrollment (Oct 15–Dec 7)
Medicare Advantage Open Enrollment (Jan 1–Mar 31) if already on MA
Some MA pla
Isn't it concerning that Medicare Advantage plans are taking over the system?
Charise Karjala here from Palm Springs, California. The question is, isn't it concerning that Medicare Advantage plans are taking over the system? It's an interesting question, and I'm gonna tackle it in a couple of different ways.
Number one, I'm gonna refute that they are taking over the system. There are many, many people who do not want to have Medicare Advantage, poor and rich people alike. They opt to spend their resources where they choose. If they choose to have a Medicare or a Medigap policy and a drug plan, that's their choice, and they put their money where their preferences are.
Medicare Advantage is a system of affordable care that provides embedded benefits over and above Medicare CMS guidelines. They do all of the care stuff that gets done, and they throw in benefits like dental, vision, rides, over-the-counter items, food, and it goes on and on—hearing aids, and yeah, it's wonderful. Medicare Advantage policies cost our country far less than Medicare policies do, and in so doing, they save us taxpayers money and also save the consumer money. The consumer pays for a Medicare Advantage plan, their Medicare Part B premium, whatever that is, which fluctuates, and then they pay basically nothing else other than some copays, up to a maximum out-of-pocket of around $1,000 a year. It's brilliant. What's the matter with that?
Well, what's the matter with that is what are you giving up to get access to that affordability? Where I see the problem with Medicare Advantage is that the transparency of the network compromises the plans that are being made on an annualized basis. There is value in working with a broker who understands the complexities of the networks in any given community, especially ones that they live and work in. The consumer does not have the benefit of understanding the size and the ability to access different providers within their network. This is a major drawback of the Medicare Advantage policies. I hate to hear of my clients waiting months for a referral because this stuff not only should not be happening in Medicare Advantage.
So there's your answer: Are they taking over the system? No.
Why would you not choose a medicare Advantage plan?
There are many reasons!The most important reason is, I prefer to have control over my health, rather than a privatized corporation! In an MA plan, you have to follow their rules, see their doctors, facilities, and get referrals before you can go anywhere. If you have a consultation with a practitioner, and find you don't like or trust him/her, you do not have the choice to look elsewhere! You are going to THAT DOCTOR! So my preference, on the major medical items, at least, I want to know that I have the options for the BEST treatments I can get and not worry about the costs either, because I chose the best by opting for Original Medicare, and an affordable supplement, that gives ME the control over who I see. Accepting an MA plan means you eliminate yourself from having coverage through top facilities such as The Mayo Clinic, The Cleveland Clinic, Johns Hopkins, Moffett, etc.
Also, I often see the annual deductible cost more than Original Medicare and a Supplement combined! Why would you opt then to put yourself in a controlled box? You are most likely paying for your Part B already in most MA programs. If the annual deductible is more than the yearly supplement, then it truly doesn't benefit you.
MA Plans rarely travel with you because they are dependent on the local Network of Doctors, hospitals, and participating specialists. If you travel, this is of no use to you. Everything will be out of pocket or at least out of network. And if you travel internationally, the MA plan is absolutely no good for you, whereas the supplement plans give you a $50,000 lifetime, 80% reimbursement payment for any medical services outside the USA.
Lastly, the consistency of changes to what the government allows for, and what the MA companies will cover, is constantly changing from year to year. So you have to review and babysit your medical each year! The doctor in the plan this year may elect not to accept it next year!
Don't get caught saving nickels to spend Benjamins on later!
What should I do if I find out that my preferred hospital isn't in-network with my Medicare Advantage plan?
You are able to change your Medicare Advantage Plan during the Annual Enrollment Period, ( AEP, October 15 through December 7th), for an effective date of January 1. You are also entitled to change your Medicare Advantage Plan during the Open Enrollment Period, (OEP, January 1 through March 31st) of each year. If your Hospital non-participation with your Insurance Plan is a new development, for example the Hospital recently terminated its agreement with the insurance plan, you may also be entitled to a Special Election Period, (SEP), and allowed to switch your plan. A Medicare Insurance Agent can help you determine your eligibility to switch your plan and other options that may be available to you.
Hey, I keep hearing about Medicare Advantage plans everywhere. What's the real deal with those compared to regular Medicare?
Original Medicare will cover 80% of covered charges, leaving the beneficiary to pay the other 20%. To help with that 20% out of pocket amount, the two solutions are referred to as "Medicare Advantage" plans and "Medigap" (Medicare Supplement) plans.Advantage plans cover everything but copays or coinsurance for services used (fee-for-service model) and will typically not charge a monthly premium. Many times an Advantage plan will include Part D prescription drug (Rx) benefits at no additional premium and can even offer cheaper Rx copays than a stand-alone Rx plan. In addition, Advantage plans can include extra benefits not covered by Medicare, such as dental, vision, hearing, gym membership, and other benefits.
Medigap (Supplement) plans cover the majority, if not all, of your out of pocket medical expense, but charge a substantial monthly premium regardless of how often you use medical services. In addition, Medigap does NOT cover Rx medications, so you are required to enroll in a separate Rx drug plan which will likely also include an additional separate premium. Medigap plans do not offer additional benefits.
Typically I only recommend Medigap for someone who has a complex medical history and risks spending more on an Advantage plan's Maximum Out Of Pocket limit (MOOP) than it would cost to pay the annual premium on the Medigap supplement plan. (MOOP is a safety net with Advantage Plans that prevent you from any catastrophic expenses). Another reason would be to accommodate extenuating provider network access issues. Some people prefer Medigap over Advantage plans because they might have enough financial cushion to not factor premiums into their decision. They simply want the psychological safety of knowing everything is paid for without having to reconcile copays or medical bills.
In my view, it's easy to see why Medicare Advantage plans have become so popular. Who wouldn't want more for less?
I need a hearing aid but I've heard Medicare doesn't cover them. Is there any way around this?
You’re right — Original Medicare (Parts A & B) does not cover routine hearing exams or hearing aids.But there are several practical ways people get hearing aid coverage or lower the cost. Here are your best options, clearly laid out:
1. Medicare Advantage plans (Part C) — most common workaround
Many Medicare Advantage (MA) plans include hearing benefits, such as:
Hearing exams
Allowances for hearing aids (often $1,000–$3,000 per ear every 1–3 years)
Access to large networks (UnitedHealthcare, Humana, Anthem, etc.)
⚠️ Important:
Benefits vary by plan and county
Usually must use in-network providers
Often requires prior authorization
➡️ This is the only Medicare path that routinely includes hearing aids.
2. VA benefits (if applicable)
If you’re a veteran:
The VA often covers hearing exams and hearing aids at low or no cost
Even partial service-connected hearing loss can qualify
3. Medicaid or Medicare Savings Programs (income-based)
If you qualify for Medicaid or a Medicare Savings Program:
Some states cover hearing aids
Coverage varies by state and medical necessity rules
4. Costco, Sam’s Club, and direct-to-consumer options
If coverage isn’t available:
Costco hearing aids: often $1,500–$2,000 per pair
OTC FDA-approved hearing aids (for mild to moderate loss): $300–$1,000
Direct-to-consumer audiology programs with remote fitting
💡 These are often cheaper than using insurance.
5. Flex cards, OTC cards, or supplemental benefits
Some Medicare Advantage plans offer:
OTC allowances
Flex cards
These sometimes can be used toward hearing-related costs (plan-specific).
6. Timing strategy (important)
If you currently have:
Original Medicare + Medigap → no hearing aid coverage
You can switch to a Medicare Advantage plan during Annual Enrollment (Oct 15–Dec 7)
Or during Medicare Advantage Open Enrollment (Jan 1–Mar 31) if already on MA
Coverage would start the month your MA plan is effective.
Why might Original Medicare with a Part D plan be better than a Medicare Advantage plan for frequent travelers?
One thing many older adults wonder is whether their Medicare benefits are portable. If you travel often within the U.S., you should know original Medicare covers hospital care and doctor visits in all 50 U.S. states as well as Washington, D.C., Puerto Rico; the U.S. Virgin Islands; Guam; American Samoa; and the Northern Mariana Islands. There are no network restrictions; you can see any provider that accepts Medicare.What about Medicare Advantage? The issue of coverage area isn't as straightforward. Certain Medicare Advantage plans do provide state-to-state coverage, including a national pharmacy network that allows you to pick up your prescription medications at locations across the country. However, other Medicare Advantage plans may not cover care outside of their defined service area—or they may impose higher cost-sharing or prior-authorization rules for out-of-network care.
Note: Both original Medicare and Medicare Advantage plans are required to cover emergency and urgent care anywhere in the U.S. without additional restrictions or out-of-pocket costs.
Will you be spending a large amount of time at a second home, with family, or at a long-term vacation rental? If you have an Medicare Advantage plan, be sure you understand its rules before heading out on an extended stay. This is because:
With many Medicare Advantage plans, you’re limited in the amount of time you can spend outside your service area and still be covered (e.g., six months). For example, if you’re a snowbird who spends winters in Florida, you can remain there for six consecutive months and maintain your Medicare Advantage coverage. If you stay longer than that, you may be disenrolled from the plan and automatically enrolled in original Medicare. While six months is common, some MA plans allow you to travel continuously within the U.S. for up to one year and still keep your benefits.
I've got a Medicare Advantage plan, and I'm curious if my upcoming eye surgery is fully covered or if I'll owe extra out of pocket.
The honest answer is: it depends on your specific surgery, your specific Medicare Advantage plan, and whether the providers are in-network.For many Medicare Advantage plans, eye surgery is not automatically “fully covered” just because you have the plan. You may still have:
* Copays or coinsurance
* Deductibles
* Specialist fees
* Facility or outpatient surgery charges
* Anesthesia charges
* Higher costs if the surgeon or facility is out of network
* Prior authorization requirements
A few important examples:
* Cataract surgery: Often covered when medically necessary, but you may still owe copays/coinsurance and upgraded lenses may cost extra.
* Vision correction procedures (like LASIK): Usually not covered because they are often considered elective.
* Retinal surgery, glaucoma surgery, or other medically necessary procedures: Coverage often exists, but cost-sharing varies.
The fastest way to know:
Call the member services number on the back of your card and ask
Do I need a Hospital Indemnity Plan if I have Medicare Advantage? What if I am hospitalized twice in the same year?
Nearly every Medicare Advantage plan charges a copay for the first several days of a hospital stay (commonly $300–$400/day for days 1–5 or 1–7), so that cost is coming whether or not you have Hospital Indemnity. The recommended move is picking an indemnity plan that pays a matching daily benefit for those same days, so it offsets that copay dollar-for-dollar instead of leaving it as a large out-of-pocket surprise.On being hospitalized twice: the general rule is that if the second stay happens within 60 days of leaving the hospital the first time, it's the same benefit period, so you're not starting the copay over. But if there's more than a 60-day gap between stays, it counts as a new admission and the copay resets to day 1— meaning you could pay that $300–$400/day charge a second time in the same year til your max days. That's another scenario that Hospital Indemnity plans are built to cover.
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?
With Medicare Advantage plans or Part C, it is difficult when there are generalizations that the plans include dental coverage. It is really important to know what coverage is included with each of the plans. Worse yet, over the years, the high profile celebrities come in and advertise "free" benefits and may share details that licensed, appointed and certified agents cannot and many would not say that are advertised on T.V. Although there have been attempts at regulating what is advertised on T.V., it is important to identify and understand the details of the plans according to the Plan ID.Medicare itself does not include dental coverage. It is considered to be a value added benefit. It can be added to Part C or Medicare Advantage plans. Insurance carriers can choose to offer discount coverage which many do not consider true dental coverage, or can offer just preventative or basic coverage, and some opt to include more comprehensive coverage.
The "Evidence of Coverage" will reveal the details of the coverage which can be found on the insurance carriers website, Medicare.gov, and agents should be able to provide or send the evidence of coverage or summary of benefits documents that will outline the coverage.
As legislation has changed and insurance carriers evaluate utilization and rising healthcare costs, insurance carriers have had to adjust what benefits can be offered or have had to place maximum limits for items such as dental as well as vision and hearing coverage that may be added to plans. The Value Based Insurance Designs are sunsetting at the end of 2025 that were instituted in 2017. This has prompted insurance carriers to reevaluate benefits that may be included in the plans.
Why do doctors not like Medicare Advantage plans?
Here is why your doctor might have a "love-hate" (mostly hate) relationship with them:1. The "Prior Authorization" Paperwork
This is the number one complaint. In Original Medicare, if a doctor says you need an MRI or a specific surgery, you generally just get it.
The MA Reality: Private insurers often require "prior authorization" for services. This means your doctor’s staff must spend hours submitting paperwork to prove the service is necessary.
The Friction: In 2026, even with new laws requiring faster decisions (7 days for routine, 72 hours for urgent), doctors still find this an administrative nightmare that delays your care and increases their overhead costs.
2. Higher Denial Rates
Doctors get frustrated when they prescribe a treatment plan only to have an insurance company’s algorithm or remote medical reviewer deny it.
The Conflict: Studies consistently show that MA plans deny a higher percentage of claims than Original Medicare. When a claim is denied, the doctor either doesn't get paid or has to engage in a lengthy, unpaid appeals process to fight for your treatment.
3. "Narrow" Networks
Medicare Advantage plans save money by limiting you to a specific "network" of doctors.
The Doctor's Perspective: This makes referrals difficult. If your primary care doctor wants to send you to the best specialist in the city, but that specialist isn't in your plan's network, the doctor has to hunt for a "second-best" option that is covered. This limits their ability to provide what they consider the highest quality of care.
4. Reimbursement Lag & Lower Pay
In 2026, the gap between what Medicare pays doctors and what it costs to run a practice has widened.
The Money Trail: While the government increased payments to MA insurance companies by about 4.3% for 2026, many doctors saw their actual reimbursement rates stay flat or even decrease.
The Result: Some hospitals are "dropping" certain MA plans entirely because the administrative cost.
What's the key difference in how Medicare Advantage and Medigap handle out-of-network providers?
One of the biggest differences between Medicare Advantage and Medigap is how they handle doctors and hospitals that are out-of-network.Medicare Advantage (Part C)
Medicare Advantage plans usually work like an HMO or PPO, which means they have a set network of doctors and hospitals. If you go outside that network:
With an HMO, it often won’t be covered at all (unless it’s an emergency).
With a PPO, you can go out-of-network, but you’ll likely pay more.
These plans are usually tied to a local or regional network, so if you travel a lot or live part of the year in another state, it’s something to consider. Also, some plans may require referrals to see a specialist.
Medigap (Medicare Supplement)
Medigap works alongside Original Medicare, and there are no provider networks. You can see any doctor or specialist in the U.S. who takes Medicare, no matter where you are. No referrals needed. This kind of flexibility can be a big plus—especially if you want to keep your current doctors or travel frequently.
Serving ALL of Texas, California & Florida
Legal: This information is intended for general guidance only and does not guarantee that Medicare or any Medicare Supplement or Advantage Plan will cover specific services or claims. All coverage decisions, authorizations, and payments are made solely by Medicare and/or your plan provider based on your individual eligibility, medical necessity, and current policy rules. Always consult with your healthcare provider and plan administrator to confirm your benefits and coverage before starting any treatment.
Why do some people regret choosing a Medicare Advantage plan over Original Medicare?
The short answer: Medicare Advantage looks great on paper, but can create problems when you actually need care.The most common regrets:
Network restrictions. Advantage plans limit you to specific doctors and hospitals. If your doctor leaves the network — or you need a specialist — you may be stuck or paying out-of-pocket.
Prior authorizations. Many services require the plan’s approval before you get care. Denials and delays frustrate people who expected seamless coverage.
Out-of-pocket costs add up. Low premiums are appealing, but copays, coinsurance, and the annual MOOP (up to $9,350 in-network in 2025) can surprise people with serious health events.
Travel limitations. Most Advantage plans only cover emergencies outside their service area. Snowbirds and frequent travelers often get caught off guard.
Can’t easily switch back. If you want to return to Original Medicare and add a Medigap plan, you may face medical underwriting in most states — meaning you could be denied or pay much higher premiums based on health conditions.
What is the trap of Medicare Advantage plans?
Medicare Advantage can look like the easy choice — low or $0 premiums, bundled extras — but there are some serious tradeoffs that you may not realize until it’s too late.Your doctor or hospital could disappear from your plan.
Provider networks are renegotiated every 1–3 years. That top-rated hospital or specialist you rely on? They could be out-of-network next year, and you’re left scrambling. If you live with a chronic condition, this can be devastating.
Chronic illness can drain your wallet.
If you're diagnosed with cancer, autoimmune disease, or need infusions or specialty drugs, you could hit the plan’s maximum out-of-pocket — up to $8,000+ per year depending on the plan — with no cap over time. And that's every single year.
You might lose your chance to find cost relief once you have a chronic illness.
Many people don’t realize you can’t just switch to a Medicare Supplement plan anytime. If your health changes and you now have pre-existing conditions, you can be denied a Supplement — and stuck in Advantage with higher long-term costs and fewer choices.
Bottom line: Medicare Advantage works for many — but it’s not risk-free. If staying in control of your care, costs, and providers matters to you, we need to talk through all the options first to understand the tradeoffs and your risk tolerance.
Why are people unhappy with Medicare Advantage plans?
-Medicare Advantage plans can have a high annual maximum out-of-pocket limit.-The annual maximum out-of-pocket limit often increases annually.
-Your choice of care is most often restricted to network providers.
-Coverage when traveling out of the service are is most often limited to emergencies only.
-Higher costs when receiving treatment out-of-network.
-Referral to a specialist may be required which can delay treatment.
-Proprietary prior authorization, beyond Medicare's authorization, can delay or deny treatment.
-Most Medicare Advantage plans have annual changes.
-Some Medicare Advantage companies have pulled out of the market or rural areas - less choice of available plans.
-Some Medicare Advantage companies are now offering only HMO plans.
-HMO plans - think cost-containment
-The Part D coverage was improved but government subsidies did not increase enough, causing Medicare Advantage plans to increase deductibles, copays, coinsurance, maximum out-of-pocket, eliminate or reduce extra benefits, cut back staff...
-Some Medicare Advantage plan companies are no longer paying agents. Most stand-alone Part D companies no longer pay agents.
What's the best way to avoid surprise bills for lab tests under Medicare Advantage?
The single best way to avoid surprise lab bills with a Medicare Advantage plan is to make sure both the doctor and the laboratory are in your plan's network before the test is performed. Many Medicare Advantage plans require you to use specific labs, and a test sent to an out-of-network laboratory can result in higher costs or even no coverage at all.Here are the steps I recommend to clients:
1. Ask one simple question every time
When your doctor orders lab work, ask:
"Which lab will process this test, and is that lab in-network for my Medicare Advantage plan?"
Don't assume the doctor's office knows your plan's network rules.
2. Verify with your insurance company
Before the blood draw, call the member services number on your card and ask:
Is this lab in-network?
Does this test require prior authorization?
What will my copay or coinsurance be?
Getting confirmation beforehand can save a lot of frustration later.
3. If the specimen is collected in the doctor's office
Ask where it will be sent.
Many surprise bills happen when an in-network physician sends blood work to an out-of-network lab without the patient realizing it.
Isn't it suspicious that Medicare Advantage plans offer gift cards and incentives to enroll?
That’s a great question, and this is going to be a bit of a long answer because there’s a lot to think about with it.I’m guessing you’re talking about the over the counter cards or the healthy foods benefit cards. The grocery cards you’ve heard about are not incentives to enroll, they’re actually benefits included in certain Medicare Advantage plans. These cards are typically part of what’s called an ‘over-the-counter (OTC) or healthy foods benefit,’ and they’re meant to help members afford nutritious food, which supports better health outcomes.
As far as gift cards, Medicare has strict rules that prohibit offering gifts over a certain value to influence enrollment decisions. What you typically see are small, government-approved tokens, usually under $15, used to encourage people to attend educational events or complete health assessments after they’re already enrolled. These are designed to promote preventive care and overall wellness, not to sway anyone’s plan choice.
The grocery cards or Flex Cards you see advertised, especially with dual-eligible Medicare Advantage plans, are not sign-up incentives. They’re actually approved supplemental benefits offered to people who qualify for both Medicare and Medicaid.
These benefits are designed to support low-income individuals with things like groceries, over-the-counter items, or utilities, depending on the plan. The government allows Medicare Advantage plans to provide these extra benefits to improve health outcomes and help members manage chronic conditions.
So, it’s not about getting a gift for enrolling, it’s about providing real, ongoing support to those who qualify.
Providing the best healthcare plan for each individual should be the focus of any agent when helping a client with a healthcare plan.
My Advantage plan says I need a referral just to see a dermatologist. I thought PPOs didn't require that - was I wrong?
Generally, no, you do not need a referral to see a dermatologist if you have a Medicare Advantage PPO plan.PPO plans (Preferred Provider Organizations) are designed for flexibility. Unlike HMO plans, which usually require a "gatekeeper" primary care physician to approve specialist visits, PPO plans allow you to book appointments directly with specialists.
However, there are a few practical nuances to keep in mind for 2026:
1. In-Network vs. Out-of-Network
In-Network: You can see any dermatologist in your plan’s network without a referral. This will result in the lowest out-of-pocket cost (usually a standard copay).
Out-of-Network: You can still see a dermatologist who isn't in your plan’s network without a referral, provided they accept Medicare. However, you will likely pay a higher coinsurance or a higher copay for these visits.
2. Prior Authorization
While you don't need a referral (a note from your GP), your plan might still require prior authorization for specific procedures. For example, a routine skin check usually doesn't need approval, but a complex surgery or specialized laser treatment might require the dermatologist to get the "thumbs up" from your insurance company first.
3. Specialist Office Policies
Even if your insurance doesn't require a referral, some dermatology offices have their own internal policies and may ask for a referral from a primary care doctor before they will schedule you. This is more common for high-demand specialists or specific medical skin conditions.
Why are seniors losing Medicare Advantage plans?
Seniors are losing Medicare Advantage coverage due to several factors, including insurers exiting markets, rising costs, and changes in Medicare reimbursement rates. The Inflation Reduction Act (IRA) has also played a role by introducing prescription drug caps and reducing base payments to Medicare Advantage insurers, further pressuring insurers financially.Here's a more detailed breakdown:
Insurers exiting markets:
Many insurers are pulling out of specific markets or reducing their plan offerings, which directly impacts seniors who previously had those plans. This can be due to factors like rising costs, changes in reimbursement rates, or simply being unable to continue operating profitably in certain areas.
Rising costs:
Medicare Advantage plans are experiencing increased costs, including those related to higher utilization of care and changes in prescription drug costs due to the IRA.
Changes in Medicare reimbursement rates:
The IRA has introduced changes to how Medicare Advantage plans are reimbursed, which can impact their financial viability and lead to plan closures or reductions in benefits.
Prior authorization and payment issues:
Many health systems have cited excessive prior authorization denial rates and slow payments from insurers as reasons for dropping Medicare Advantage plans, further impacting seniors.
Prescription drug costs:
The IRA's prescription drug caps and rising copays have also contributed to the increased costs faced by seniors and insurers, potentially leading to more plan changes or closures.
"Trapped" seniors:
Some seniors feel "trapped" in Medicare Advantage plans due to their complex structures, narrow networks, and limited options when facing serious medical needs. This can lead to frustration and a desire to switch to traditional Medicare.
What if I missed my window to sign up?
There are a LOT of moving parts to this question. For the sake of simplicity I am assuming you’re saying you missed the 7 month window (3 months before your birth month, your month of birth, and 3 months after) to sign up for Medicare.You can call Social Security anytime to sign up for Part A as long you qualify for premium-free Part A (you’ve worked and paid into the system for at least 40 quarters, or 10 years).
For Part B, there’s a General Enrollment Period (GEP) from January 1st to March 31st each year, with Part B starting July 1st. If you were eligible this year, and signed up in GEP 2027, you will pay a 10% monthly penalty ($20.25 at the 2026 rate) per year you missed. It’s cumulative, so if you didn’t sign up until GEP 2028, you’d pay 20%, etc. It’s also permanent, so you pay that penalty as long as you have Part B coverage.
If you don’t qualify for premium free Part A, the same GEP applies, and the 10% penalty applies, but it only lasts for twice as long as you went without coverage. So the part A penalty is finite, the Part B penalty follows you forever.
However, if you have employer coverage or spousal coverage that can be considered creditable (VA coverage, COBRA, and ACA coverage are not creditable) then you have a different situation.
Your best bet is to talk to agent to review your situation in detail to see if any special election periods apply that can help you.
Which is better: a Medicare Advantage Plan or a Medigap policy?
Neither a Medicare Advantage plan nor a Medigap policy is inherently "better"; the right choice depends on your individual needs and preferences. Medicare Advantage plans are private, bundled alternatives to Original Medicare that often include drug coverage, vision, dental, and hearing benefits, but restrict your choice of providers to a plan network. Medigap policies, on the other hand, are supplemental to Original Medicare and cover out-of-pocket costs like deductibles and copayments, providing freedom to see any provider who accepts Medicare but without the bundled extra benefits of Advantage plans.Choose Medicare Advantage if:
You want bundled benefits: These plans can combine your Part A, Part B, and Part D (prescription drug) coverage, plus extras like vision, dental, and hearing care, all into one plan.
You prefer lower monthly premiums: Advantage plans often have low or even $0 monthly premiums, though you'll still pay copays or coinsurance for services.
You don't mind a limited provider network: You must use providers within the plan's network for your care, so it's important to ensure your doctors are in the network.
Choose a Medigap Policy if:
You value freedom of choice: Medigap plans allow you to see any doctor or hospital that accepts Original Medicare, regardless of location or network restrictions.
You want predictable costs: Medigap policies help cover the remaining out-of-pocket costs that Original Medicare doesn't pay, such as deductibles, copayments, and coinsurance.
You prefer to keep Original Medicare: Medigap is a supplement to Original Medicare, whereas Medicare Advantage plans are a replacement for it. You can also buy a separate Part D plan for prescription drugs.
What are disadvantages of HMO?
Here are some common disadvantages of HMO (Health Maintenance Organization) plans:1. Limited Provider Network
• You must use doctors, specialists, and hospitals within the plan’s network.
• Out-of-network care usually isn’t covered (except for emergencies).
2. Primary Care Physician (PCP) Requirement
• You’re required to choose a PCP.
• All specialist visits usually need a referral from your PCP, which can slow down care.
3. Less Flexibility
• Unlike PPOs, you don’t have freedom to see providers outside the network without paying the full cost.
• This can be a problem if you travel often or need a specific specialist not in the network.
4. Geographic Restrictions
• HMOs typically serve a local/regional area.
• Care outside that service area may not be covered unless it’s an emergency.
5. Limited Specialist Access
• You may face longer wait times for referrals or see fewer specialists compared to other plan types.
6. Potential for Higher Out-of-Pocket Costs If Out-of-Network
• If you mistakenly go outside the network, you’re usually responsible for the entire bill.
7. Less Patient Autonomy
• The referral system and care coordination through your PCP may feel restrictive to people who prefer more control over their care choices.
What's the process for signing up for Medicare if I'm already on disability benefits?
If you are already receiving Social Security Disability Insurance (SSDI) benefits, the transition to Medicare is typically automatic. In most cases, you don't need to take any action to sign up. The Standard 24-Month Rule. For most individuals under age 65, Medicare coverage begins after you have received disability benefits for 24 months. Automatic Enrollment: You will be automatically enrolled in Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) starting in your 25th month of disability benefits. Notification: You should receive a Medicare welcome package and your Medicare card in the mail approximately 3 months before your coverage is set to begin. Exceptions to the Waiting Period: Certain medical conditions allow for immediate or expedited enrollment without the 24-month wait: ALS (Lou Gehrig’s Disease): You are automatically enrolled in Medicare Parts A and B the same month your disability benefits begin. End-Stage Renal Disease (ESRD): You are eligible for Medicare regardless of age, but you usually must apply manually through Social Security rather than waiting for automatic enrollment. Key ConsiderationsPart B Premiums: While Part A is generally premium-free, Part B has a monthly premium ($185.00 for most in 2025; $202.90 in 2026). This amount is usually deducted automatically from your monthly disability check. Declining Part B: If you have other health coverage (like through a spouse's current employer), you can opt out of Part B by following the instructions in your welcome package. However, if your employer has fewer than 100 employees, Medicare is typically the primary payer, and you may need Part B to avoid coverage gaps. Additional Coverage: You will still need to decide if you want to join a Medicare Advantage Plan (Part C) or a Prescription Drug Plan (Part D), which requires separate enrollment.
When can I change my Medicare Advantage Plan?
You can change your Medicare Advantage plan at a few specific times during the year, and it’s actually simpler than most people think. There are three main windows when changes are allowed.The first is every fall, from October 15th to December 7th. This is the big annual enrollment period. During this time, anyone on Medicare can review their plan, compare options, and switch to a different Medicare Advantage plan if they want to. Any changes you make during this window start on January 1st.
The second window is from January 1st to March 31st, but this one is only for people who are already enrolled in a Medicare Advantage plan. If you start the year and realize your plan isn’t working for you — maybe your doctor isn’t in the network, your medications aren’t covered the way you expected, or the copays are too high — you get one chance to switch to another Medicare Advantage plan or go back to Original Medicare with a Part D plan.
The third way to change your plan is through what’s called a Special Enrollment Period. These happen when life changes — things like moving to a new county, losing Medicaid, your plan leaving the area, or qualifying for a chronic condition plan. These special situations allow you to make a change outside the normal windows.
So the simple version is this: you can change your Medicare Advantage plan every fall, once at the beginning of the year if you’re already in an MA plan, and anytime during the year if a qualifying life event gives you a Special Enrollment Period.
Do Medicare Advantage plans save money?
The question of whether Medicare Advantage plans save money is complex, with varying perspectives. Here's a breakdown of key considerations:Potential Cost Savings for Individuals:
* Lower or Zero Premiums:
* Many Medicare Advantage plans offer low or even $0 monthly premiums.
* Out-of-Pocket Maximums:
* These plans typically have a limit on your annual out-of-pocket expenses, providing a degree of financial protection. Traditional Medicare lacks this cap.
* Additional Benefits:
* Many Medicare Advantage plans include benefits not covered by Original Medicare, such as dental, vision, and hearing care, which can lead to cost savings if you utilize these services.
* Consolidated Coverage:
* Medicare Advantage plans often combine Medicare Part A, Part B, and Part D (prescription drug coverage) into a single plan, streamlining costs.
Concerns About Overall Costs:
* Higher Costs to the Medicare System:
* Reports, such as those from the Medicare Payment Advisory Commission (MedPAC), indicate that Medicare Advantage plans can cost the Medicare system more than Original Medicare. This is due to factors like how the plans are paid, and coding intensity.
* Potential for Hidden Costs:
* While premiums may be low, Medicare Advantage plans can involve copayments, coinsurance, and other out-of-pocket costs that can accumulate.
* Prior Authorizations and Network Restrictions:
* Medicare Advantage plans often require prior authorizations for services and have network restrictions, which can limit access to certain providers and potentially lead to unexpected costs.
In summary:
* For some individuals, Medicare Advantage plans can offer potential cost savings through lower premiums and added benefits.
* However, from the perspective of the overall Medicare program, there are concerns that these plans may increase costs.
* It is very important for an individual to carefully review the details of any medicare advantage plan they are considering.
What are the most overhyped benefits of Medicare Advantage plans that seniors should be wary of?
Seniors should be cautious about overhyped benefits in Medicare Advantage plans, particularly regarding "free" benefits like dental or vision coverage, as these often come with limitations or caps. They should also be wary of claims of lower premiums or no out-of-pocket costs, as copays & coinsurance can still apply. Here's a more detailed breakdown of what to watch out for:1. "Free" or Limited Benefits:
Dental and Vision: Brochures & ads may tout "free" dental or vision coverage, but average coverage limits for vision are often minimal (e.g., $160), and dental coverage may have annual dollar limits (e.g., $1,000 or less).
Fitness:
Fitness benefits might have restrictions on usage times or gym access.
2. Copays and Out-of-Pocket Costs:
Despite $0 premiums:
Many plans have zero premiums, but beneficiaries still have to pay copays and coinsurance for services.
Annual maximums don't cover everything:
The annual maximum out-of-pocket costs for medical care often exclude prescription drug costs.
3. Network Restrictions and Prior Authorization:
Provider Networks:
Some plans restrict coverage to in-network providers, limiting choices for specialists or preferred doctors.
Prior Authorization:
Many plans require prior authorization for certain services, which can delay or even deny care.
4. High Premiums and Unexpected Costs:
Monthly Premiums:
While some plans may have low or zero premiums, beneficiaries still need to factor in the Medicare Part B premium, which is $185 in 2025, according to the National Council on Aging (NCOA).
Unexpected Costs:
Some beneficiaries may face unexpectedly high costs when they become ill or discover that their network lacks the necessary providers.
In short, seniors should carefully evaluate Medicare Advantage plans beyond the surface-level benefits and consider the potential drawbacks like network restrictions, prior authorization, and hidden costs.
With the supplements being so expensive in climbing in price every year, what is your take on hospital indemnity policies added with advantage policies?
My take on hospital indemnity policies paired with Medicare Advantage plans is that it's ABSOLUTELY something I recommend and encourage to *all* of my Medicare Advantage clients, every time.In fact, Medicare itself *allows* us to discuss the following coverage with our clients in the Medicare Scope of Appointment form that must be signed by the beneficiary every year as a compliance requirement.
Medicare Advantage, Medicare Supplement, Prescription Drug Plans, Dental, Vision, Hearing & Hospital Indemnity Plans.
The copays and coinsurance costs on a Medicare Advantage plan are generally really low for doctor visits, lab work, x-rays and urgent care, but the costs for ambulance, outpatient surgery, inpatient hospitalization and skilled nursing facility coverage add up really quickly in the event of medical events.
I make it a practice to keep track of the copays on the plans my clients select for their Medicare Advantage plans, and pair a thorough, robust, budget-friendly hospital indemnity plan for them. It's rare that my clients ever regret adding that coverage. I've heard from numerous clients who did *not* add it, that they regret the copays they've been charged after a sudden medical event.
I exercise regularly and maintain a healthy lifestyle. Does Medicare offer any incentives or additional benefits for preventive health behaviors?
While Original Medicare doesn't offer direct financial incentives or rewards for maintaining a healthy lifestyle, it does provide coverage for preventive services that can help you stay healthy and potentially avoid future health issues.Medicare-covered preventive services that support a healthy lifestyle:
Annual Wellness Visit: This visit allows you to develop or update a personalized prevention plan with your doctor, including discussing healthy lifestyle choices.
Screenings: Medicare covers various screenings like mammograms, colorectal cancer screenings, and cardiovascular screenings, which can help detect potential problems early.
Counseling: Medicare covers counseling services for things like obesity, alcohol misuse, and tobacco use, which can help you make healthier choices.
Vaccinations: Medicare covers vaccines for the flu, pneumonia, and hepatitis B, which can help protect you from illness.
Medicare Diabetes Prevention Program: If you have prediabetes, Medicare covers a program to help you prevent type 2 diabetes through lifestyle changes.
Medicare Advantage plans and additional benefits:
Many Medicare Advantage plans (Part C) offer additional benefits that can support a healthy lifestyle, such as:
Fitness programs: Some plans may include gym memberships or fitness programs like SilverSneakers or Renew Active.
Wellness programs: These may include services like vision, hearing, and dental care, or even virtual check-ups.
Rewards programs: Some Medicare Advantage plans have started to offer rewards or incentives for completing healthy activities, like getting a flu shot. However, these programs and the specific incentives offered can vary by plan, so it's important to check the details of any plan you're considering.
Key takeaway:
While Original Medicare focuses on covering preventive services, You can check with your specific Medicare plan to see what Medicare Advantage plans often offer additional benefits that can support a healthy lifestyle.
Why are people leaving Medicare Advantage plans?
People leave Medicare Advantage plans for a few recurring reasons:They want broader provider choice. Many Medicare Advantage plans use provider networks, and people may switch if their doctors or hospitals are out of network or if they travel and want fewer network limits.
They run into prior authorization or coverage denials. Some members leave after delays or hassles getting approvals for services, rehab, imaging, or certain drugs.
Costs become less predictable than expected. Even with low or $0 premiums, members can face copays/coinsurance that add up, higher costs for frequent care, and hitting the plan’s annual out-of-pocket maximum.
Their plan changes from year to year. Networks, drug formularies, premiums, and cost-sharing can change annually, and a “good” plan one year may fit poorly the next.
They prefer Original Medicare’s structure. Some people switch because they want fewer plan rules, easier use of out-of-area providers, or the option to pair Original Medicare with a Medigap policy (when available/affordable).
They feel they enrolled based on confusing marketing. Some beneficiaries later realize key limitations (like networks or prior authorization) were not fully understood at sign-up.
One important caution is that switching from Medicare Advantage to Original Medicare does not always guarantee you can buy a Medigap plan without medical underwriting, depending on your state and timing.
My Medicare Advantage plan denied coverage for a specialist I need to see. What are my options now?
Options:1. First- ask your Primary Care Provider if they were able to submit the prior authorization, supporting notes and documentation required for the request; if yes and still denied;
2. Consider asking the Primary Care Provider to do a Peer to Peer call with the plan Medical Director for further discussion and insight around the plan's decision;
3. Appeal the decision through the carrier specific appeal process and be prepared to present all supporting documentation and address the reason for the denial specifically as part of the strategy;
4. If still denied and deemed necessary by your primary care provider/treatment team; escalate the appeal through the carrier to the next level of review and appeal;
5. If no resolution and the treatment team deems the referral as absolutely necessary and there is peer reviewed, evidence based, clinical support and medical necessity, you can escalate the appeal to CMS through their appeal process.
Typically, the denial is related to lack of prior authorization being filed, lack of supporting documentation and/or clinical evidence of medical necessity, or failure to comply with step therapy and conservative treatment options first. In fact, most of the denials are overturned when they have the supporting information and there is medical necessity to support the request.
You can always reach out member service of the plan or contact your local, trusted, Licensed Medicare Agent for support and guidance around the how to appeal and navigate the process.
Does Medicare Advantage cover acupuncture or alternative therapies in some plans?
Yes, some Medicare Advantage plans do cover acupuncture and other alternative therapies — but coverage can vary quite a bit depending on the specific plan.Original Medicare (Part B) does cover acupuncture, but only for chronic lower back pain — and only under specific conditions. You’re allowed up to 12 visits in 90 days, and if your condition improves, Medicare may approve 8 more sessions (for a total of 20 in a year). The provider must meet certain requirements, and you’ll usually pay 20% of the cost after meeting your deductible.
When it comes to other alternative therapies like massage therapy, naturopathy, or treatments for conditions besides back pain, Original Medicare typically doesn’t cover them.
Medicare Advantage (Part C) is different. These plans are offered by private insurance companies and are required to cover everything Original Medicare does — but many plans go further and include extra benefits. Some may offer more extensive acupuncture coverage, or even cover things like massage therapy, wellness programs, or other integrative treatments. However, not all plans include these benefits, so it depends on the insurer and the plan you choose.
If alternative or holistic therapies are important to you, it’s worth checking the specific details of each Medicare Advantage plan. Look at the Summary of Benefits and ask questions like:
Does the plan cover acupuncture beyond back pain?
Are massage or other therapies included?
Are there limits on how many visits you can have?
Do you need a referral or pre-approval?
Every plan is different, so it’s a good idea to compare options based on what matters most to you.
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I have Medicare Advantage with a PPO, and I'm curious if my annual wellness visit is free or if I'll owe something for it.
If you have a Medicare Advantage plan with a PPO (Preferred Provider Organization), your annual wellness visit is generally free. However, there are some important details to consider to understand how it works with your specific plan.What Is an Annual Wellness Visit?
An Annual Wellness Visit (AWV) is a preventive service that Medicare covers to help assess your overall health and identify any potential issues before they become serious. It’s not the same as a routine physical exam, but rather a visit with your primary care doctor to review your health history, risk factors, and create a preventive care plan for the upcoming year. The visit may include:
A health risk assessment.
A review of your medical history and medications.
A list of screenings and immunizations you may need.
A discussion about healthy lifestyle choices.
Coverage Under Medicare Advantage (PPO):
Medicare Advantage plans are required to cover everything Original Medicare covers, including the Annual Wellness Visit. However, because you have a PPO plan, there are a few things to consider regarding how your specific plan works:
Preventive Services Are Typically Covered at No Cost:
Most Medicare Advantage PPO plans will cover the Annual Wellness Visit with no out-of-pocket cost, as long as you stay within the plan's guidelines. This means you should not have to pay a copayment or coinsurance for the wellness visit itself if it’s coded correctly as a preventive service and is not linked to any additional treatment or procedures.
Out-of-Network Providers:
If you see an out-of-network provider for your wellness visit, your PPO plan will likely still cover it, but the cost-sharing might differ compared to seeing an in-network provider. In-network providers typically charge lower copayments, and you may pay more if you see someone out-of-network.
I have heard of some people's providers dropping their Medicare Advantage plans. Should I be worried about this?
It can happen, but it’s usually not something to panic about — it’s a normal part of the Medicare Advantage (MA) landscape. Here’s what you need to know:Why providers drop MA plans
Network contracts change – Insurers renegotiate with doctors and hospitals yearly.
Financial or administrative reasons – Some providers decide the reimbursement rates or paperwork aren’t worth it.
Plan changes – Your MA plan may change its network rules during Annual Enrollment.
What it means for you
If your primary doctor leaves the network, you may:
Pay higher out-of-pocket costs for out-of-network care (if your plan allows it)
Need to choose a new in-network provider
If your hospital leaves, elective procedures may need to be at a different facility
How to protect yourself
Check your plan’s network each year
MA networks can change January 1; your plan is required to send updates.
Ask about continuity of care
If your doctor leaves, Medicare requires some plans to provide temporary coverage for ongoing treatment.
Annual Enrollment Period (Oct 15 – Dec 7)
You can switch MA plans or return to Original Medicare + Part D/Medigap if your provider leaves.
Call your plan before procedures
Confirm that your doctor and hospital are still in-network to avoid surprise bills.
Bottom line:
Yes, it’s possible your provider could leave an MA network, but staying informed, checking networks annually, and knowing your enrollment options protects you from major surprises.
What is the Medicare Advantage 5-Star Special Enrollment Period? Is this different from '"OEP'" and "AEP"?
The Medicare Advantage 5-Star Special Enrollment Period (SEP) allows beneficiaries to switch to a 5-star-rated Medicare Advantage or Part D plan once per year, anytime between December 8 and November 30. It is distinct from AEP and OEP because it is not based on a specific calendar season, but rather the availability of a high-quality plan. Differences in Enrollment Periods:5-Star SEP: Runs Dec 8–Nov 30. You can change plans once during this period, but only if a 5-star plan is available in your area. AEP (Annual Enrollment Period): Oct 15–Dec 7. Everyone with Medicare can change plans (Advantage or Drug). OEP (Open Enrollment Period): Jan 1–March 31. Only for those already in Medicare Advantage; allows one change. Key Differences Summary: The 5-star SEP is solely to move to a top-tier rated plan. Flexibility: 5-Star SEP allows changes almost all year, whereas AEP and OEP have strict, narrow windows. Requirement: A 5-star plan must be active in your service area to use the 5-star SEP.
Do your clients use Medicare Advantage over-the-counter drug cards? How does that work?
Not every Medicare Advantage plan includes an over-the-counter (OTC) benefit, but many of them do. When a plan offers it, members receive a set allowance they can use to purchase certain health and wellness items.Most plans provide a monthly or quarterly allowance, often somewhere in the range of about $25 to $100, depending on the plan. That credit can typically be used for things like pain relievers, cold and flu medicine, vitamins, allergy medications, bandages, and other basic health supplies.
How members use the benefit depends on the plan, but it usually works in one of three ways:
• Ordering items from the plan’s OTC catalog and having them shipped to their home
• Ordering through the plan’s website or mobile app
• Using a benefit card at participating retail stores
It is also worth noting that certain Special Needs Plans (SNPs) can offer much larger allowances. For example, some plans designed for people who qualify for both Medicare and Medicaid, or those who have specific chronic conditions, may provide higher monthly benefits that can be used for OTC items and sometimes other health-related expenses.
One thing many people do not realize is that these allowances usually do not roll over, so if the credit is not used during the month or quarter, it is typically lost.
If someone is unsure whether their plan includes this benefit, the easiest place to check is their Summary of Benefits or Evidence of Coverage, or they can contact their plan directly to confirm. It can be a helpful perk when available, but the details vary quite a bit from one plan to another.
Can I switch from a Medicare Advantage plan to Original Medicare with a Medigap plan mid-year if I’m diagnosed with a serious illness?
Generally no. There are, however, two scenarios where you might be able to switch from a Medicare Advantage (MA) plan to Original Medicare with a Medigap policy mid-year.The first scenario is if you moved or are about to move. Your new location might have guaranteed issue options for a new Medigap plan when you are coming from an MA plan. You have a two month window to utilize this option.
The second scenario is a concept called "Medicare trial rights (MTR)". According to Medicare.gov this is how MTRs work:
MTR #1 - If you drop a Medigap policy to join an MA plan for the first time, you’ll have a single 12-month period (your trial right period) to get your Medigap policy back if the same insurance company still sells it once you return to Original Medicare. If it isn't available, you can buy a Medigap policy you qualify for that's sold by an insurance company in your state (except for Plans M and N). You may also have an opportunity to enroll in a Medicare drug plan at this time.
MTR #2 - If you joined an MA plan when you were first eligible for Medicare Part A at 65, you can choose from any Medigap policy that's sold by an insurance company in your state if you switch to Original Medicare within the first year of joining the MA plan. You may also have an opportunity to enroll in a Medicare drug plan at this time.
As always, check with a local and reputable licensed Medicare expert. You can also check with Medicare.gov, 1-800-Medicare, and your local SHIP counselor.
What are disadvantages of PPO?
PPO Plans offer flexibility but that flexibility comes at a price. There are some notable disadvantages when compared to plans like HMOs or EPOs. Some of the main disadvantages of PPO plans are as follows:1. Higher Premiums: PPO plans typically have the highest premiums, often significantly more than HMOs or EPOs
2. Higher Out-of-Pocket Costs: This includes higher deductibles (the amount you pay before your coverage kicks in), copays, and coinsurance.
3. More expensive out-of-network care — While PPOs provide some coverage for out-of-network providers you will usually pay substantially more for those services. Expect much higher coinsurance, separate deductibles, or reduced reimbursement rates. In some cases, you may be required to pay upfront and file claims for reimbursement on your own. NOTE: Out-of-network providers are not required to write off excess charges like in-network providers are and you can be held liable for them.
4. More Responsibility Managing Personal Care: Without referrals or a designated primary care physician helping coordinate care you're mostly on your own to track provider network status, surprise bills, and handle potential paperwork/claims for out-of-network visits.
NOTE: In recent years PPO options have been disappearing in certain markets (e.g., Medicare Advantage, ACA Marketplace). Networks may be shrinking in some plans and overall costs continue trending higher due to overwhelming administrative costs and fraud. PPOs remain popular for those who value choice, like frequent travelers, those with established out-of-network specialists, or anyone wanting to see specialists without referrals. The trade-off is typically higher, less predictable expenses. If cost control or more predictable payments matter more then you should consider an HMO or EPO.
Why are hospitals not taking Medicare Advantage plans?
Some hospitals and health systems have been dropping Medicare Advantage plans or refusing to contract with certain carriers because the reimbursement rates insurers pay are often lower than what Medicare pays directly, and the prior authorization requirements have become a serious burden on their staff and patients. When a hospital spends significant time and resources fighting insurance companies for approvals on procedures that should be straightforward, it affects their ability to operate efficiently and gets in the way of patient care. This does not mean all hospitals are leaving all Medicare Advantage plans, but it is a real and growing trend worth paying attention to. If you are on a Medicare Advantage plan or considering one, it is smart to verify every year that your preferred hospitals and specialists are still in network, because networks can change on January 1st even if you stay on the same plan.
Does Medicare Advantage cover home health care?
Voss Speros here, the Greek god of Medicare. The question today is, does Medicare cover home health care? Yes, Medicare covers it. Medicare Advantage covers home health care, medical home health care. They cover medical home health care. So, like a skilled home health need, physical therapy, occupational therapy, things like that. When you're coming out of a skilled nursing facility, going home, and you need therapy, it covers that.
Non-medical home care, like custodial care, most mainstream Medicare doesn't really cover. They have a billing code for someone that oversees that. So there's a little gray area mixed in on that one. Some Advantage plans offer hours a year for non-medical home care. So yes, depending on your need and depending on your area, we can find a plan that works and has some of that coverage. But the non-medical side, it's only like 80 hours a year. It's not a lot if you need that kind of home care. Someone to come in and watch over your folks or you, you're gonna need more than 80 hours a year or an hour or a couple of hours a week.
As for medical home care, yeah, usually that's about 6 to 8 visits a month is what Medicare pays for. And then physical therapy passes through home health. If you go the physical therapy route, you can probably get about one session a day, depending on the plan. Occupational therapy, about the same thing on that one. Keep in mind, if you're on an Advantage plan and a provider says you need to drop it and go back to original Medicare for more benefits, they're lying to you. The only reason they're saying that is because they're getting a higher reimbursement rate from original Medicare than an Advantage plan. They still can do it. They just don't want to contract with it.
Or you just need to find someone that's gonna be contracted with it. If you call your plan and say, I need home health, they'll find you a contracted home health care company that can bill and take that plan. So if anybody tells you you need to drop your plan because you're getting less benefits, they are lying to you. And it's all about money. It's not about patient care at that point. It's about money. So if you want patient care, say, you know what? Thank you. Thank you for the suggestion. I'm gonna call my plan and see who's contracted. And I'm gonna go work with them. Thank you very much. Have a great day.
So just keep in mind, Medicare does cover medical home care. Medicare Advantage, straight Medicare. Hope that helps. If you have any questions, we'll send out an agent, do a plan review, and we'll get you straightened out. Have a great night.
I am moving to a different county in my same state, should I look at getting a new Medicare plan?
I assume that this question refers to a Medicare Advantage Plan (which has a defined service area). Check your existing plan Summary of Benefits or Evidence of Coverage to see if your new county is in the service area of the plan you currently have. If your existing specific plan is available in both counties, then you don't have to change plans. Be careful: Insurance companies list their plans by county, so even if the insurance company has a presence in the new county, your existing plan may not be available there.If you don't have to change plans, I would still contact the plan to change your address.
Whether or not your plan is available in the new county, I suggest you contact a local agent that understands how Medicare works and is familiar with the plans and providers available in the local area to help you determine how you want to move forward in the future.
In the case of any change to your address, be sure to update your home address with Social Security.
How can insurance companies afford to offer Advantage plans with $0 monthly premiums?
$0 premium Medicare Advantage plans can exist because they are funded differently than many people assume — they are heavily supported by federal payments.Here’s how insurers make it work:
1. Federal funding (capitation payments)
Medicare pays private insurance companies a fixed amount each month for every enrolled beneficiary. If the insurer manages care efficiently, it can use those funds to offset or eliminate the plan premium.
2. Cost-sharing structure
Even with a $0 premium, members still pay copays, coinsurance, and deductibles when they use services. This shifts part of the cost from fixed premiums to pay-as-you-go healthcare usage.
3. Network management
Most Advantage plans use provider networks and negotiated rates to control expenses, similar to employer health plans.
4. Star Ratings bonus payments
Plans that achieve high quality scores from Medicare can receive bonus funding — often used to enhance benefits or keep premiums low.
5. Supplemental benefits attract healthier members
Extras like dental, vision, and fitness help broaden the risk pool. When healthier individuals enroll, overall claims costs can decline.
I'm confused by all the star ratings for Medicare plans. Do they actually mean anything for the care I'll receive?
Medicare gives plans a 1 to 5-star rating (5 is best) based on several factors, including:• Member satisfaction (from surveys)
• Customer service
• Managing chronic conditions
• Preventive services (like screenings and vaccines)
• Drug safety and accuracy (for Part D)
Higher-rated plans usually have better customer service, fewer complaints, and do a better job helping members stay healthy.
• Plans with 4 stars or more are generally considered high quality.
• Bonus payments go to plans with 4+ stars, which can mean more money for extra benefits (like dental, vision, or OTC allowances).
Use star ratings as a starting point, but not the only factor. Always also check:
• Your doctors’ network participation
• Your prescriptions and their cost tiers
• Maximum out-of-pocket limits
• Extra benefits that matter to you (like travel coverage)
If you travel a lot or have specific health needs, sometimes a lower-rated plan might actually serve you better than a 5-star plan.
What are the types of Medicare Advantage plans?
Medicare Advantage (Part C) plans are offered by private companies approved by Medicare. They combine your hospital (Part A) and medical (Part B) coverage—and most also include prescription drug coverage (Part D). There are six main types, each with different rules, costs, and flexibility:🧭 Six Types of Medicare Advantage Plans
1. HMO (Health Maintenance Organization)
You must use doctors and hospitals in the plan’s network (except in emergencies). Referrals are needed for specialists. Most plans include drug coverage.
2. PPO (Preferred Provider Organization)
You can see doctors outside the network, but it costs more. No referrals needed. Most plans include drug coverage.
3. PFFS (Private Fee-for-Service)
You can go to any provider who accepts the plan’s payment terms. Drug coverage may or may not be included. These plans are less common.
4. SNP (Special Needs Plan)
Designed for people with specific health conditions, those in care facilities, or those who qualify for both Medicare and Medicaid. Always includes drug coverage.
5. MSA (Medical Savings Account)
Combines a high-deductible plan with a savings account funded by Medicare to help pay for healthcare costs. Doesn’t include drug coverage—you’ll need a separate Part D plan.
6. HMO-POS (HMO Point of Service)
A mix of HMO and PPO. You can go outside the network for certain services, but it usually costs more.
If someone enrolls in a MAPD C-SNP and gets disenrolled for not providing a CCV form within 60 days, is there a SEP to enroll in another MAPD plan?
Yes, disenrollment from a C-SNP for failing to provide the Chronic Condition Verification (CCV) form within 60 days is classified as a loss of SNP eligibility. This qualifies the individual for a Special Enrollment Period (SEP) to enroll in another MAPD plan.SEP DETSAILS & RULES TIMELINE: The SEP begins the month you are notified of disenrollment and lasts for two full calendar months after the notification date.
OPTIONS: You can switch to another Medicare Advantage plan (MAPD) that you are eligible for, or switch back to Original Medicare with a standalone Prescription Drug Plan (PDP).
COVERAGE: Your new coverage will typically begin the first day of the month after you submit a completed application.
How do Medicare Advantage star ratings affect the quality of care I can expect?
When you are looking at Medicare Advantage (MA) plans, the 1-to-5-star rating system from the Centers for Medicare & Medicaid Services (CMS) is essentially a scorecard for how well a plan actually delivers on its promises. While it might look like a standard internet review system, it is built on hard data collected from medical records, member surveys, and administrative audits. Here is exactly how those stars translate to the care you receive.Better Health Outcomes. Independent health studies show that enrollees in 4- and 5-star plans generally experience better medical outcomes. For example, members in higher-rated plans are less likely to be readmitted to the hospital within 90 days of an illness because their outpatient follow-up care is managed more tightly. More "Perks" and Lower Costs. The system incentivizes insurance companies to do well. Plans that achieve 4 or 5 stars receive a financial "Quality Bonus Payment" from Medicare. By law, the insurance companies cannot just pocket this extra money—they must reinvest it back into the plan. They use these bonuses to offer lower premiums, reduced copays, or richer supplemental benefits like dental, vision, hearing, and fitness allowances. Customer Service and Access. If a plan has 4 or 5 stars, it usually means their network of doctors is reasonably stable, and they are faster at approving prior authorizations. Low-star plans (1 or 2 stars) often have higher rates of member complaints regarding claims being denied or long delays in getting care approved.
How do I find local Dentists that take my Medicare coverage?
Start by calling the number on the back of your Medicare card and asking for a list of in‑network dentists in your zip code.You can also use your plan’s website ‘Find a provider’ tool, type in your zip code, pick ‘dentist,’ and make sure to filter by your specific plan name so the results match your coverage.
Before you book, call the office to confirm they’re still taking your plan, because networks can change.
What is the Medicare Advantage 3 midnight rule?
The three-midnight rule actually applies to Original Medicare, not Medicare Advantage, and it refers to the requirement that a patient must be formally admitted as an inpatient for at least three consecutive midnights before Medicare will cover a skilled nursing facility stay. This rule trips up a lot of Medicare beneficiaries because hospitals sometimes place patients under observation status rather than formally admitting them, and observation stays do not count toward the three-midnight threshold even if you are sleeping in a hospital bed for several nights. Medicare Advantage plans handle skilled nursing facility coverage differently depending on the plan, and many have their own criteria that do not follow the three-midnight rule at all, so it is important to understand how your specific plan works before you need that benefit. If you or a loved one is ever hospitalized, it is worth asking the hospital staff directly whether you are being admitted as an inpatient or placed under observation, because that distinction can have a significant impact on what you owe.
Don't you think Medicare will eventually be privatized completely?
There’s ongoing political debate about expanding the role of private insurers in Medicare, but a complete privatization of Medicare is unlikely in the near term without major legislation and enormous political resistance.Right now, Medicare already operates as a hybrid system:
Original Medicare is government-administered.
Medicare Advantage plans are run by private insurers but funded by Medicare.
Part D prescription coverage is privately administered.
Private involvement has grown substantially over the past two decades. More than half of Medicare beneficiaries are now enrolled in Medicare Advantage plans rather than traditional Medicare.
The debate usually centers on:
whether Medicare Advantage should continue expanding,
whether traditional Medicare should remain equally available,
and how to control long-term costs as the population ages.
Supporters of more privatization argue:
competition can improve efficiency,
plans may offer extra benefits,
coordinated care models can reduce waste.
What's the most misleading Medicare Advantage ad you've seen, and how do you explain the reality to clients?
In my experience the most confusing thing are the ads on TV that talk about a “food card.” There have been various permutations of this ad over the last few years, but the crux of them is a statement that you may be eligible for a monthly debit card of $100, $200, or more, to be used for the purchase of healthy foods.I say this is confusing rather than misleading because those benefits DO exist - but only for certain people, and that’s often buried in the fine print. Also, people can tend to hear what they want to hear from a TV ad which makes the confusion worse.
The benefit is known as SSBCI - Special Supplemental Benefits for the Chronically Ill, and there are several different versions of it.
If you have medicare AND Medicaid, AND your Medicaid is the right level, you likely have access to plans that offer you a healthy benefits card. The amount on that card will vary based on your level of Medicaid and what service area you’re in. If you don’t have a Chronic Illness (CI), you can only use the card for over the counter products. If you DO have a CI, you can use it for food, utilities, even rent and transportation depending on the provider.
What if you don’t have Medicaid? There are still options available, though they don’t typically offer as much. If you have diabetes or a heart condition, there are many Chronic Special Needs Plans (CSNPs) that have a similar benefit. Generally, if you qualify for the CSNP, you’ll qualify for the SSBCI.
If you don’t have either of those conditions, but have high blood pressure, high cholesterol, certain lung conditions, or other chronic illnesses (there are several that vary by provider) you may be eligible for a plan with SSBCI included.
I personally don’t try to lure people in with a promise of these benefits. They may not qualify, and the plans often have higher copays and coinsurances than a plan without SSBCI included, but I’m happy to go over them if they match my client’s needs.
Is occupational therapy covered by Medicare Advantage with UnitedHealth?
Voss Speros here, Greek out of Medicare. If Medicare is Greek to you, you're in luck because I'm Greek. So I'm gonna break it down a little bit. The question is, is occupational therapy covered by Medicare Advantage? Yes, it is. It's usually categorized with physical therapy and speech therapy, and it's either a certain number of times a month or a dollar amount per visit. So usually it has anywhere from zero to forty dollars a month or zero to forty dollars per visit with an occupational therapist.
Occupational therapy is rearranging your house and helping you move around in your occupation to get you back moving into the occupation of work or just living in your house, moving around, and doing things. Physical therapy gets your body up and running and strong enough to go out and do those things. Occupational therapy helps you reorganize and get you to move around and find out what you need to do to be able to function in your own house again. So yes, it is covered by Advantage plans. Depending on the carrier, there's a different copayment for service. If you have questions, give us a call. Hope you have a good day.
Isn't Medicare Advantage just private health insurance? What is the difference?
The difference between Medicare Supplement and Medicare Advantage plans. Many people think these things are the same. They're actually quite different. A Medicare Advantage plan is typically either an HMO or PPO type of plan where you have to worry about doctors and hospitals being in network. They're usually a lower premium than a Medicare Supplement. And depending on where you are, certain service areas have a zero premium plan which does not cost you anything above and beyond what you would normally pay for just the Part B premium.
Medicare Advantage plans typically do include prescription drugs. They do have a maximum out-of-pocket, referred to as MOOP, of a maximum of $9,350. So that is your worst-case scenario. Even if something catastrophic were to happen, they will give you some coverage, usually for dental, vision, and hearing. But it's usually not comprehensive, but more preventative. So for dental, things like checkups and cleanings, sometimes they will offer a rider to give you more comprehensive dental coverage.
The Medicare Advantage plans are locked in for one year, and you can only get the plans that are in your service area. With Medicare Supplement, you will pay a higher premium, but you do get better coverage. You don't have to worry about networks. You can go to any doctor or any hospital that you want. Medicare Supplements do not include prescription drugs, so you'd probably also want to get a standalone prescription drug plan. Medicare Supplement will also not give you anything towards dental, vision, and hearing. But again, you can get a standalone dental, vision, and hearing plan.
Medicare Supplements can also be changed at any time throughout the year. Unlike Medicare Advantage and prescription drug plans, you're locked in for the year and you can't change it till the end of the year for a January 1st effective date. The first time you get a Medicare Supplement, you will get a guaranteed issue, so you don't have to answer health questions. But after that, in the future, if you want to change to a different plan or different carrier, you will need to go through health underwriting and answer health questions. And there are no service areas that you have to worry about.
Don't you think Medicare should ban all those celebrity Medicare Advantage commercials?
Many people, including government officials, think Medicare should ban or heavily regulate celebrity-driven Medicare Advantage commercials due to concerns about their misleading nature & potential to confuse seniors. These ads often promote the idea that seniors are missing out on benefits by not enrolling in Medicare Advantage & some have been found to use deceptive tactics to get people to sign up. Here's why there's a push for tighter regulation:Deceptive & Misleading Claims: Ads often claim that seniors are missing out on benefits, including higher Social Security payments, to encourage them to call broker hotlines.
Misleading Information: Some ads don't fully disclose that Medicare Advantage plans have limited networks of doctors & hospitals, potentially leading seniors to switch plans only to find they can't see their preferred providers.
Predatory Sales Tactics: Brokers & agents using hotlines have been accused of using "bait-and-switch" tactics & other misleading techniques to enroll seniors in plans.
Confusion for Seniors: The sheer volume of these ads, combined with their misleading claims, can make it difficult for seniors to understand their Medicare options.
Financial Incentives for Brokers: Brokers receive higher commissions for enrolling seniors in Medicare Advantage plans than for Medigap or Part D plans, creating a financial incentive to promote Advantage plans.
Government Actions: The Centers for Medicare & Medicaid Services (CMS) is working to crack down on misleading Medicare marketing practices. Congress is also investigating Medicare Advantage plan broker pitches on TV & has proposed regulations to address deceptive advertising. Some states have seen an increase in complaints about deceptive marketing leading to further investigations & proposals for stricter regulations.
In essence, the concern is that these ads are not providing seniors with accurate & unbiased information, making it difficult for them to make informed decisions.
Will Medicare Advantage plans start offering more digital health tools like apps by 2030?
Yes, it is highly likely that Medicare Advantage plans will offer more digital health tools like apps by 2030.Here's why:
Growing adoption of digital health: Since the COVID-19 pandemic, telehealth and other remote healthcare services have gained significant traction, increasing their coverage by health insurance plans.
Government encouragement: The Centers for Medicare & Medicaid Services (CMS) is actively promoting the use of digital health technologies, seeking public input on how to improve beneficiaries' access to and utilization of these tools.
Market demand: Medicare Advantage members, especially newer enrollees, are increasingly comfortable with and expect digital engagement from their healthcare providers and plans.
Benefits for plans: Digital health tools can enhance patient engagement, improve care coordination, reduce readmissions, and positively impact Medicare Star Ratings, which are linked to revenue and bonuses for MA plans.
Technological advancements: AI, telehealth, personalized data analytics, and blockchain are revolutionizing healthcare delivery, with significant growth projected for digital health platforms in the coming years.
Specific examples of digital health tools already being integrated into Medicare Advantage plans:
Digital therapeutics: Medicare has started covering FDA-approved digital therapeutics for treating specific conditions like depression and anxiety.
Personalized care plans: Digital health apps can provide members with tailored care plans based on their medical information.
Telehealth and online scheduling: These tools facilitate virtual consultations and make it easier for members to connect with providers.
Remote monitoring devices: Wearable devices and health trackers help members manage chronic conditions and collect valuable health data.
Member portals and apps: Many Medicare Advantage plans offer online platforms for members to access their health information, manage benefits, and communicate with their plan.
If we choose a Medicare Advantage plan and later regret it, can we go back to Original Medicare without penalties?
Yes, there are no "penalties" if you choose to go back. You always have "original Medicare" that pays 80% of your costs. When you first turn 65, you have a choice to stay on original Medicare with a supplement or choose Advantage. If you choose the advantage, you can drop the plan and go back to original Medicare each year between Oct 15th and Dec. 7th. It's the SUPPLEMENT that is hard to get back on, just depending. 1.) When you turn 65, you have "guaranteed issue" rights to be on a supplement plan without going through underwriting. 2.) If your advantage plan drops you, you have another opportunity for "guaranteed issue" and can get a supplement without question. 3.) If you choose the supplement first, and want to try an advantage plan in the fall, you have a year to try it; if you do not like it, you can go back to the Supplement on "guarantee rights" again. "Your Trial Right". So you have several opportunities to go to a supplement plan, you just have to understand how it works, so you can make smart choices for yourself. Also, later in life, you can drop your Advantage plan, go back to original Medicare, and ASK for a Supplement Plan, but you will have to go through underwriting, and if you have any medical issues or preexisting conditions, they will not take you. However, Advantage Plans do not have "underwriting," they take everyone, it doesn't matter what their medical conditions. Hope this helps..... Kim HumphriesWhat shift has been observed in Medicare spending, particularly regarding Medicare Advantage plans?
Medicare spending has shifted towards Medicare Advantage plans, with spending on these plans exceeding traditional Medicare for Part A and Part B benefits since 2023. This shift is driven by rising enrollment in Medicare Advantage and higher payments to these plans compared to traditional Medicare.Here's a more detailed look:
Increased Enrollment:
The percentage of beneficiaries enrolled in Medicare Advantage has steadily increased, reaching over 50% of eligible Medicare beneficiaries in 2020.
Growing Spending:
Payments to Medicare Advantage plans have nearly tripled between 2011 and 2021, growing from 26% to 47% of total Part A and B spending.
Higher Payments:
Medicare pays more per beneficiary in Medicare Advantage plans than in traditional Medicare, with estimates suggesting an extra $83 billion in 2024 due to upcoding, favorable selection, and quality bonuses.
Projected Growth:
Medicare spending on Medicare Advantage benefits is expected to continue growing, reaching 60% of total Part A and B spending by 2031, according to a KFF analysis.
Reasons for Growth:
The shift is fueled by factors like zero-premium plans, extra benefits (vision, dental, etc.), out-of-pocket limits, and a desire for more convenient access to care.
This shift raises questions about Medicare's long-term solvency and affordability, as Medicare Advantage plans are paid on average significantly more than traditional Medicare for similar beneficiaries.
Are some Medicare Advantage providers better than others?
Yes, some Medicare Advantage carriers are definitely better than others.But "better" really depends on what matters most to you. Some have low copays but few doctors in their network. Others cover a wide range of providers but are a nightmare when it comes to customer service or don't cover your specific medications. Some make it hard to get things approved or change up your meds halfway through the year, which no one enjoys dealing with.
The key is knowing how the plan actually works in your area and not just what the brochure says or what worked for your neighbor. What looks great on paper might be a mess once you try to use it.
No one plan or carrier is a great fit for everyone. That’s why we take the time to match people with plans that fit them and their situations. We’ve seen the good, the bad, and the ones that look good until the fine print kicks in.
If I’m in a Medicare Advantage plan, will I still need prior authorization for procedures next year?
Yes, if you're in a Medicare Advantage (MA) plan, you may still need prior authorization (PA) for certain procedures, tests, or treatments next year. Medicare Advantage plans are offered by private insurers and they often have specific rules and requirements for covered services, which may include prior authorization.The need for prior authorization depends on the specific plan and the type of service you're seeking. For example, some plans might require prior authorization for elective surgeries, expensive diagnostic tests, certain medications, or specialty care. The requirements and the process for getting approval may vary from one insurer to another and from one type of care to another.
To know exactly what will require prior authorization next year:
Review your plan’s formulary or benefits guide: This should be updated for the new year, and it will list which services require prior authorization.
Talk to your insurer: If you’re uncertain about any upcoming procedures or treatments, it’s always a good idea to contact your Medicare Advantage plan’s customer service to confirm.
Discuss with your doctor: Your healthcare provider can often help navigate the prior authorization process, as they will be familiar with which services tend to require it and can submit the necessary paperwork on your behalf.
It’s good to plan ahead because prior authorization can sometimes take time to process, and delays could impact when you can get a procedure or treatment.
Are there any guidelines I should follow when filling out my Medicare application?
Guidelines for Seniors Filling Out a Medicare ApplicationFilling out a Medicare application is an important step in securing your health coverage as you age. To help make the process smoother and avoid mistakes, here are some key guidelines to follow:
1. Know when you’re eligible and what enrollment periods apply
You’re generally eligible for Medicare when you turn 65, or earlier if you have certain disabilities, end-stage renal disease (ESRD), or ALS.
The Initial Enrollment Period (IEP) is a 7-month window: 3 months before your 65th birthday, the month of your birthday, and 3 months after.
If you miss the IEP, you may have to apply during a General Enrollment Period (January 1–March 31 each year) and could face late enrollment penalties.
If you (or your spouse) are working past 65 and have employer group health coverage, you may qualify for a Special Enrollment Period to delay Medicare without penalty.
Center for Medicare Advocacy
2. Gather all required documentation ahead of time
Before you begin filling out the application, make sure you have:
Your Social Security number
Proof of citizenship or legal residency
Your date of birth
Information about your current health insurance (if any)
If applying for Part B separately, the CMS-40B form is required.
Centers for Medicare & Medicaid Services
If your employer or spouse’s employer had group health coverage, you may need to submit CMS-L564 to document when coverage ends.
Having everything ready reduces delays and mistakes.
3. Fill out the application carefully and completely
Write legibly and avoid leaving blanks
How will the recent attention & auditing around Medicare Advantage plans effect nursing home coverage?
With Nursing home coverage you shouldn't rely on any type of Medicare plan be it Medicare Advantage, Medicare Supplement or Original Medicare for long term custodial care but if you're talking about short term stays for Rehab you will get up to 100 days covered on any plan. You should either look at Long term care insurance or if youre nelow poverty level you could apply for Medicaid.The benefit of a Medicare Advantage plan is that they will cover those short term stays without any prior hospital stay whereas Original Medicare or Original Medicare plus Medicae Supplement requires a 3 day prior Inpatient Hospital stay before they cover it.
With Medicare Advantage plans they do require Nursing facilities to submit clinical information before extending stays which sometimes Nursing home staff are lazy to do. If your plan denies an extended stay is 90 percent of the time because the staff at the Nursing home hasnt given them the clinical information to support the request for extended stay. If you have a broker your broker can help you file an appeal and also put pressure on the Nursinh home staff to submit the required clinical information to get your stay extended
I did that for my father in law successfully and have done it for several other clients as well
More broadly even Original Medicare as well as Medicare Advantage plans will be cracking down on Nursing homes for submitting too little clinical information and will require them to start providing more detailed diagnosis
Can my Medicare Advantage plan offer extra coverage for breast cancer services?
Can a Medicare Advantage plan offer extra benefits for breast cancer? So I think the first place to start here is that a Medicare Advantage plan has to offer the same services as Original Medicare. That's things like your annual screening, your mammograms, diagnostic manual grants, and medically necessary treatment.
Now under the Advantage plan, there may be a cost-sharing just like there is under Original Medicare, where Medicare Advantage can provide you with additional services. These can include expanded screening, access to additional tools, transportation to and from doctor's appointments or lab visits, and care coordination. That's oftentimes coordinating care among various different doctors, which can be a very useful tool, especially when you have a family member helping you guide your treatment.
Potential access to genetic treatments or genetic testing far in advance of a diagnosis may also be available. And then post-treatment support may be available under your Medicare Advantage plan. Now every plan is going to be different. Some plans may offer some services while another may not.
I think the other thing to consider prior to a diagnosis with Medicare Advantage plans is that if you have a cancer diagnosis, you may have some significant cost-sharing up to the plan's maximum out-of-pocket. To help cover that and protect your financial wellness, we always recommend a standalone cancer plan with a Medicare Advantage plan. So if you're pre-diagnosis, that might be something to look at.
If you have any questions, Medicare.gov provides a lot of resources. Reach out to your local senior center or to your insurance company to find out which specific services they have available to you. Until next time, be healthy and be well.
How is Medicare Advantage expected to evolve in the future?
Medicare Advantage is expected to keep growing, offering even more benefits, stronger care coordination, and more personalized plans. Carriers are investing in things like telehealth, chronic-condition support, and supplemental benefits—while also tightening networks and focusing on value-based care to keep costs down. Seniors can expect more choices, more technology, and plans designed around individual health needs.
Do Medicare Advantage plans work in rural areas?
Thank you for the chance to answer this important question.The short answer is yes. But I am always wary of the type of Medicare Advantage plan that I recommend to my clients. There are two types of plans. The plans that offer the highest benefit levels are Health Maintenance Organizations {HMO}. These plans have coverage In-Network only. There is no coverage for hospitals or doctors outside of the contracted network.
So, if you are in a rural area and are considering an HMO, you need to confirm, confirm and confirm that your local hospital and your doctors are In-Network. Also, regarding most HMO's, there is no coverage outside of the service area, i.e, the state, except for emergency room coverage. So choose wisely.
Now, the other type of plan is a Preferred Provider Organization {PPO}. A PPO has In-Network and Out-of-Network coverage. This means that any doctor or hospital that accepts Medicare must accept your plan.
SO, when you hear a family member, friend or doctor say that this or that company does not work with/for them, know that they likely have an HMO.
What's the catch of having a PPO? Less generous benefits {food card; Part B Giveback; MOOP} are the typical trade-off for having ubiquitous coverage... anywhere, anytime.
Thanks again and God bless.
What’s the difference between what Original Medicare covers and what a Medicare Advantage plan might include for holistic care?
Original Medicare provides very little coverage for holistic or alternative care — it only pays for a few very specific services like chiropractic spinal manipulation for an active subluxation or acupuncture for chronic low back pain.Medicare Advantage plans may offer some holistic benefits, but it varies widely by plan and is never guaranteed. These extras can change every year, may require prior authorization, and often come with limits.
So the honest answer is: it depends — but in most cases, holistic care is not covered under either option.
Can I be turned down for a Medicare Advantage plan because of my health?
You generally cannot be turned down for a Medicare Advantage plan because of your health, as long as you’re eligible for Medicare Parts A and B and live in the plan’s service area.Enrollment and health conditions
Medicare Advantage plans (Part C) are required to accept you regardless of pre‑existing conditions; they must follow the same “no health underwriting” rule as Original Medicare for eligibility.
Since 2021, people with End‑Stage Renal Disease (ESRD) can also enroll in most Medicare Advantage plans, which used to be a major exception.
Plans also cannot drop you from coverage later just because your health gets worse, as long as you keep paying premiums and meet basic plan rules.
When a plan can say “no”
A Medicare Advantage plan can’t deny you based on health, but it can deny enrollment for non‑medical reasons such as:
You don’t have both Part A and Part B.
You don’t live in the plan’s service area or network county.
You try to enroll outside of an allowed enrollment period (Initial Coverage Election Period, Annual Enrollment Period, or a qualifying Special Enrollment Period).
You are enrolled in certain types of other coverage that are incompatible with that plan (for example, another Medicare Advantage plan at the same time).
Coverage limits vs enrollment denial
Even though you can’t be turned down for health reasons, the plan can have rules about which doctors you can see (network), which drugs are covered (formulary), and when you need prior authorization or step therapy.
A plan must cover all services that Original Medicare covers and cannot refuse medically necessary care, but it may deny particular services if it decides they are not medically necessary under Medicare rules, in which case you have appeal rights.
Medicare Advantage vs Medigap (important distinction)
Medicare Supplement (Medigap) plans are different: outside of your first Medigap open‑enrollment or certain guaranteed‑issue situations, a Medigap insurer can use medical underwr
What is the Medicare Advantage (Part C) Open Enrollment period?
The Medicare Advantage Open Enrollment Period (MA OEP) is a specific window of time each year that allows beneficiaries already enrolled in a Medicare Advantage Plan to switch or drop their plan.It is distinct from the fall Annual Enrollment Period (AEP) because you generally cannot use this time to join a Medicare Advantage plan if you are currently on Original Medicare.
Dates
January 1 – March 31 every year.
Who Can Use It?
This period is strictly for individuals who are already enrolled in a Medicare Advantage (Part C) plan as of January 1.
What Changes Can You Make?
During this window, you are allowed to make one change to your coverage. The new coverage typically begins the first day of the month after you make the request.
You can:
Switch to a different Medicare Advantage Plan (with or without drug coverage).
Drop your Medicare Advantage Plan and return to Original Medicare.
Join a separate Medicare prescription drug plan (Part D) if you return to Original Medicare.
What You Cannot Do
You cannot switch from Original Medicare to a Medicare Advantage plan.
You cannot switch from one standalone Part D prescription drug plan to another.
Does Medicare cover SilverSneakers gym memberships?
Quick answer: not through Original Medicare — but often yes through Medicare Advantage.Original Medicare (Parts A & B) does not include SilverSneakers, but many Medicare Advantage (Part C) plans and some Medigap plans do — at no additional cost beyond plan premiums.
About 95% of Medicare Advantage plans include some form of fitness benefit.
What SilverSneakers includes:
Access to roughly 14,000 locations nationwide, fitness equipment, group classes (yoga, tai chi, water aerobics, Zumba, strength & balance), plus pools, tennis courts, and walking tracks where available.
What is the Medicare Give Back Benefit and how does it lower my Part B premium?
What is the Medicare Give Back Benefit and how does it lower my Part B premium?The Medicare Give Back Benefit, also called a Part B premium reduction, is offered by some Medicare Advantage plans. It means the insurance carrier pays a portion of your Medicare Part B premium for you.
For 2026, the standard Medicare Part B premium is $202.90 per month. Some Medicare Advantage plans may reduce that amount by giving back part of the premium. For example, if a plan offers a $50 giveback, your Social Security deduction for Part B may be reduced by $50.
The important thing to understand is that a giveback does not mean Medicare Part B is free, and it does not eliminate your need to keep Part B. You still must have Medicare Part A and Part B, and you must continue paying any remaining Part B premium to stay enrolled in the Medicare Advantage plan. Medicare Advantage plan premiums, copays, deductibles, coinsurance, and out-of-pocket costs vary by plan.
Here’s the tradeoff: some plans that offer a giveback may have higher out-of-pocket costs, higher copays, smaller provider networks, or different drug coverage. So while the plan may lower your monthly Part B premium, it may not always lower your total healthcare costs.
That’s why I would not pick a plan based on the giveback alone. The better question is: after we review your doctors, prescriptions, hospitals, copays, and maximum out-of-pocket exposure, does the giveback plan still make sense?
I've been retired and on Medicare for 4 years. Why did my Part B premium increase by almost $100?
Your part B premium is based on your income from 2 years prior. Most often, a large increase in your Part B premium, after being on it for several years, is due to an IRMAA surcharge you incur due to a large influx of income. The most common causes of this include a large IRA withdrawal, the sale of a business, the sale of real estate, or a ROTH conversion. The proceeds from all these transactions are counted as income. This increase could trigger an IRMAA charge that will last for a year.
Do Medicare Advantage plans include dental coverage?
Yes. Most Medicare Advantage plans include some level of dental coverage, while Original Medicare generally does not cover routine dental care. In recent years, about 98% of Medicare Advantage plans have offered dental benefits, but the amount and type of coverage vary significantly by plan and location.Common dental benefits may include:
* Routine exams
* Teeth cleanings
* Dental X-rays
* Fillings
* Extractions
* Crowns
* Root canals
* Dentures
* Sometimes implants (depending on the specific plan)
However, there are important limitations:
* Annual maximum benefit amounts often apply.
* Many plans require you to use network dentists.
* Major services may have copays or coinsurance.
* Benefits can change from year to year.
When speaking with Medicare beneficiaries, I would explain it this way:
“Many Medicare Advantage plans do offer dental coverage, but not all dental benefits are the same. One plan may only cover cleanings and exams, while another may also help pay for crowns, dentures, root canals, or even implants. That’s why it’s important to review the specific plan’s dental benefits rather than assuming all Medicare Advantage plans provide the same coverage.”
As an independent Medicare agent, this is also a good opportunity to remind clients that dental coverage should be just one factor in choosing a plan. Their doctors, hospitals, prescriptions, copays, and maximum out-of-pocket costs are often even more important considerations than the dental benefit alone.
We take the extra step to go through a thorough needs analysis to make sure we’re addressing all of your needs, including Dental vision, hearing, doctors, medications, hospitals, and essential needs to give you the clarity and transparency. You deserve a qualified Medicare agent with the aloha spirit. Contact us for non-Medicare assistance.
How do I change my Medicare plan during open enrollment?
People often confuse Open Enrollment with Annual Enrollment, so I’ll address both.Annual enrollment (AEP) lasts from October 15th to December 7th each year. You can enroll in a medicare advantage plan or prescription drug plan, disenroll (go back to original medicare) or change your coverage. You can make multiple changes in this time frame. Whatever plan you’ve set up as of close of business December 7th is the plan you’ll have come January 1st.
How do you change your coverage? All you need to do is enroll in the new plan you want (on or after October 15th). The disenrollment from your current coverage happens automatically so you don’t even need to contact them. You can enroll via the carrier’s web site, through Medicare.gov, or with the assistance of a licensed sales agent (my favorite option). A sales agent will work with you to ensure your doctors accept the new plan, your medications are covered, you’re not sacrificing something important in the process, etc. They’ll compare the plans they’re appointed with in your area and present you with the options.
Open enrollment (MA-OEP) happens from January 1st to March 31st and is only for people with a Medicare Advantage plan in place. Agents aren’t allowed to market this enrollment period so many people don’t know about it. In AEP, people often change plans and find out in the new year they don’t like the new one, or they hear about a plan their neighbor got and wish they had signed up for that one instead. MA-OEP gives people ONE change - think of it as a do-over - in the first quarter. Any changes go into effect the 1st of the next month, and after April 1, for most people the ability to change again won’t happen until the next AEP. The process to enroll in a new plan is the same as in AEP.
AEP is just around the corner so I hope this was helpful!!
How can I tell if my Medicare Advantage plan is financially sustainable long-term?
Medicare Advantage rules and funding change annually. You should look to make sure your plan is a consistently highly-rated carrier for the best safeguard against sudden plan withdrawals or benefit reductions. If they have a Star Rating that is a 4 or higher this means they will be receiving additional funds from CMS and provide better financial stability. You should also make sure to check the financial rating from A.M. Best, Moody's and Standard and Poor's and look that your carrier is A rated or higher.Are there really zero-premium Medicare Advantage plans, and what's the catch?
Yes, zero-premium Medicare Advantage plans are real. Medicare pays private insurers a fixed amount per enrollee (currently in the neighborhood of $12,000 per year in 2026). Insurers can use these payments to cover benefits without charging you an extra premium and still make a profit. Many also bundle in Part D prescription drugs, dental, vision, hearing, fitness, and/or transportation. You still pay the Medicare Part B premium, some plans offer a "Part B giveback" that reduces or offsets this, but not all plans do.The Catches-
Out-of-pocket costs: Zero premium doesn’t mean zero costs. You’ll still face deductibles, copays, and coinsurance for doctor visits, hospital stays, and drugs. Plans cap your annual out-of-pocket maximum, after which they cover 100%.
Network restrictions: Most zero-premium plans are HMOs that require in-network providers and sometimes specialist referrals. Out-of-network care is usually not covered, except emergencies. PPOs may give more flexibility but cost more when used outside the network.
Higher costs for heavy users: Healthy people often save money. Those with chronic conditions, frequent hospitalizations, or expensive drugs may pay more overall than someone with Original Medicare and a good Medigap policy.
Annual changes: Benefits, networks, drug lists, and extras can change every year during open enrollment. Dental, vision, hearing, and other perks have annual caps and can be reduced or eliminated.
Why do some hospitals not accept Medicare Advantage plans for cancer treatment?
Top Reasons-Too much paperwork and denials: Medicare Advantage plans often require “prior approval” for cancer treatments. This creates extra work, delays, and more denials than Original Medicare.
Lower and slower payments: These plans usually pay hospitals less than traditional Medicare for the same care. Cancer treatment is expensive, so some centers lose money. Insurers may also take longer to pay.
Limited networks: Medicare Advantage uses smaller networks, and many top cancer centers are excluded.
How This Affects You-
Original Medicare gives you access to almost any hospital or doctor that accepts Medicare, with much less paperwork. However, it has no yearly out-of-pocket limit.
What You Would Typically Pay-
Part A (hospital/surgery): Deductible per benefit period + daily coinsurance for long stays.
Part B (outpatient chemo, radiation, doctor visits): After the deductible, 20% coinsurance with no maximum.
Prescription drugs: Covered under Part D with its own deductible, copays, and out-of-pocket maximum.
Example: $100,000 in outpatient care could cost you $20,000 or more out-of-pocket. Immunotherapy and targeted drugs will cost even more.
How Most People Protect Themselves-
A Medigap policy usually covers the 20% coinsurance and deductibles, often bringing costs close to zero. You can buy any Medigap plan guaranteed issue (no health questions or denials) during the first 6 months after enrolling in Part B.
Bottom line: Traditional Medicare gives you broad access to doctors and hospitals with little prior authorization hassle, which is great for cancer care. But without a Medigap plan, a serious diagnosis can create large and unpredictable bills because there is no maximum on your liability.
Do most doctors accept Medicare Advantage plans?
Throughout the US, about 46% of doctors who are contracted with Medicare, accept some Medicare advantage plans; unlike original Medicare, which is accepted by over 90% of physicians. The best way to find out if all your doctors take a specific plan is based on a one-on-one consultation with an independent insurance agent who can help verify and go over your concerns.
How do I switch back to Original Medicare from a Medicare Advantage plan, and will I face any penalties or coverage gaps?
You can switch from a Medicare Advantage plan back to Original Medicare during the Annual Enrollment Period (Oct 15–Dec 7) or the Medicare Advantage Open Enrollment Period (Jan 1–Mar 31). Special Enrollment Periods may also apply in certain situations.There is no penalty for switching back. However, you may face a Part D late enrollment penalty if you go more than 63 days without creditable drug coverage.
Be aware of potential coverage gaps, particularly with Medigap (supplement) plans—depending on your situation, you may not have guaranteed acceptance and could be subject to medical underwriting.
Is there a penalty for switching from Medicare Advantage back to Original Medicare?
There is no penalty for switching back from Medicare Advantage to Original Medicare. However, there are several things you need to consider before doing so. Most important, you need to be aware that you will likely need to pass underwriting, which will consist of a medical review. In some cases, depending on the state, there are also anniversary or birthday rules, where you can switch without an underwriting requirement. Other major considerations are below:1) Original Medicare is a 80/20 plan with no stop gap. Therefore, if you have a chronic condition or a catastrophic health event, you could be responsible for very large medical bills. I recommend that you apply for a Medigap or Medicare Supplement plan that would pick up the majority of the 20% covered costs. This however, is an additional premium on top of the Part B premium ($202.90) that you would already be paying monthly.
2) If you move to Original Medicare and a Supplement, you will also be responsible for enrolling in a stand alone Part D plan to cover your prescription drug costs. This is also another monthly premium (average premium is approximately $45 monthly).
3) Your Medicare Advantage plan also bundles dental, hearing and vision. Original Medicare and Supplements do not cover these ancillary services. If you want coverage for dental, vision or hearing, you would also need to consider a rider to your supplement, or a stand alone plan. These will run between $30-$80 monthly.
4) The timing of this change is also an important consideration. You can change to Original Medicare from a Medicare Advantage Plan during the annual enrollment period (AEP) 10/15-12/7 (change would be effective with January 1), or you can change during the Open enrollment Period (OEP) January- March (change would be effective the following month).
If this is something that you are seriously considering, I recommend that you reach out to a local Medicare broker that can walk you through each of these considerations.
How can Medicare Advantage plans have a $0 premium? Where does the money come from?
Medicare Advantage plans can show a $0 premium because Medicare is basically paying the insurance company behind the scenes. Medicare sends them a set amount every month for each person on the plan, and if the plan doesn’t spend all of that on admin and benefits, they can use the leftover to drop your premium to $0 or even lower.The amount Medicare pays changes by county, which is why some areas have tons of $0 plans and others barely have any.
And just to be clear — $0 premium does not mean $0 cost. You’ll still have copays, coinsurance, and out‑of‑pocket costs when you actually use the plan. It just means you’re not paying a monthly premium on top of that.
Can You Be Denied a Medicare Advantage Plan?
As long as you apply for a plan during a valid election period and you meet the eligibility requirements, you can't be denied.To qualify for a Medicare Advantage plan, you must have both part A and part B of Medicare. Some plans have additional requirements such as plans designed for people who have a chronic condition such as diabetes or heart conditions. There are also plans designed specifically for people who also have Medicaid and may contain additional requirements that look into the level of Medicaid or state wavers. It's always best to work with an experienced agent to help guide you through the process of choosing and enrolling into a plan.
Can my Medicare Advantage plan drop me, and what happens if it does?
In most cases, a Medicare Advantage plan cannot simply drop you because you have health problems or because you are using your benefits. However, there are certain situations where your coverage can end:* You move outside the plan’s service area.
* You lose eligibility for Medicare Parts A or B.
* You fail to pay any required plan premiums.
* The plan terminates its contract with Medicare.
* The insurance company decides to discontinue the plan. (medicare.gov)
What Happens If Your Plan Ends?
If your Medicare Advantage plan is discontinued or its contract with Medicare is not renewed, you will receive advance notice and typically have a Special Enrollment Period to choose another Medicare Advantage plan or return to Original Medicare. Depending on your circumstances and state, you may also have certain protections when applying for a Medicare Supplement (Medigap) policy. (medicare.gov)
The Bottom Line
A Medicare Advantage plan cannot drop you simply because you become sick, develop a chronic condition, or use expensive healthcare services. If your plan does leave the market or you become ineligible, Medicare provides opportunities to choose new coverage so you’re not left without healthcare benefits.
Have questions about Medicare Advantage plans, prescription coverage, dental benefits, or other healthcare concerns? Visit Ohana Medicare. We offer concise clarity to important Medicare questions, helping you understand and manage your healthcare benefits with your best interests in mind. Explore our resources and educational content designed to help you make informed healthcare decisions with confidence
What is a $0 premium Medicare Advantage plan, and what's the catch?
A $0 premium Medicare Advantage plan means you do not pay an additional monthly premium to the plan beyond your Medicare Part B premium. However, “$0 premium” does not mean $0 cost — you may still have copays, coinsurance, deductibles, and other out-of-pocket expenses when you receive care.These plans also typically use provider networks and may require prior authorizations for certain services. The key is to look beyond the premium and review the plan’s Maximum Out-of-Pocket (MOOP), provider network, drug coverage, and cost-sharing structure before enrolling.
Do I need to carry my Medicare card if I have a Medicare Advantage plan?
If you have a Medicare Advantage plan, you typically do not need to carry your Medicare card with you. You will receive a card to reflect your Part C Medicare Advantage plan that will take over for original Medicare.However, it is very important that you still retain or keep your red, white and blue Medicare card in a safe place. Should you need to change your Medicare Advantage Plan or return back to Original Medicare and add a Medicare Supplement Plan / Medigap plan and Part D Prescription Drug Plan, then you will need your red, white and blue Medicare card to be able to change plans.
Only in rare situations will medical professionals ask for your Medicare card if you have a Medicare Advantage plan. For example, if you are traveling outside of your network and have an emergency situation, you may want to have a copy of the card with you for claims processing and billing purposes.
Are the Medicare flex cards and grocery allowance cards I see on TV legit?
Yes, they're legitimate, but the advertising can sometimes be misleading. Some Medicare Advantage plans offer benefits such as flex cards, grocery allowances, utility assistance, or over-the-counter spending cards, but these benefits are not available in every plan or every area. The amount available, eligible purchases, and qualification requirements vary significantly by plan.It's important to understand that these benefits are offered by specific Medicare Advantage plans—not by Medicare itself. Before enrolling based on a TV commercial, make sure the plan's doctors, hospitals, prescription coverage, costs, and overall benefits fit your needs, not just the extra perks being advertised.
Are Medicare Advantage plans guaranteed issue?
Medicare Advantage plans are guaranteed issue, meaning you cannot be denied coverage or pay more for your plan based on preexisting conditions, recent diagnosis or your current health condition. However, you can only enroll in plans within your service area, have Medicare Part A and B, and enroll during valid enrollment periods.If you're concerned about managing costs during a health crisis or illness, here are some things to consider when selecting a Medicare Advantage Plan:
- look for a lower maximum out of pocket amount. This can help reduce costs for medical services that use original Medicare billing such as radiation, chemotherapy, and infusions.
- understand what services you will use or need most frequently and estimate how many visits you may need in a plan year. Then, compare copays from different plans.
- ensure that all of your providers are in network and your prescriptions are on the plan's formulary.
- $0 premium plans might not always be the best option. Plans with a premium may have lower copays for services you use the most, saving you money even with paying a monthly premium.
An experienced broker who knows your area's network of providers and plans can guide you through finding the right plan for you.
What is an HMO-POS Medicare Advantage plan, and how is it different from an HMO or PPO?
An HMO-POS (Health Maintenance Organization with a Point-of-Service option) is a hybrid plan that offers a bit more flexibility than a standard HMO but typically costs less than a PPO.Here is the breakdown of the differences:
1. HMO (The Most Restrictive)
Network: You must use doctors and hospitals within the plan’s network.
Referrals: You generally need a referral from your Primary Care Physician (PCP) to see a specialist.
Out-of-Network: Not covered at all (except for emergencies).
2. HMO-POS (The "Middle Ground")
Network: Like an HMO, you have a primary network of providers.
The "POS" Part: You are allowed to go out-of-network for certain services, but it will cost more (higher copays or coinsurance).
Referrals: You still usually need a PCP to coordinate your care, but the plan gives you "permission" to step outside the network for specific needs.
3. PPO (The Most Flexible)
Network: You can see any doctor, in or out of network, without a referral.
Cost: You pay less if you stay in-network, but you have the freedom to go anywhere that accepts the plan.
Price: Usually carries the highest monthly premium because of this total flexibility.
In short: An HMO-POS is an HMO that lets you "sneak" out of the network occasionally for a higher price, whereas a PPO gives you a standing invitation to go anywhere you like.
How do Medicare Advantage plans make money if many have $0 premiums?
Medicare Advantage plans receive a monthly payment from Medicare for each enrolled member, regardless of whether the plan charges a premium. They also collect any copays, coinsurance, and deductibles required under the plan.Plans manage costs through provider networks, negotiated rates, care management programs, and utilization controls such as prior authorization. In addition, plans that earn high quality ratings from the Centers for Medicare & Medicaid Services may receive bonus payments.
That’s why a plan can offer a $0 premium and still operate profitably.
Can I change my Medicare plan after open enrollment ends?
The Short answer is yes, but the long answer requires me to go into more detail.If you just turned 65 and used your open enrollment option on a plan, then you need to wait till the Annual enrollment, which starts 10/15 of each year and ends on 12/7, to make changes. These changes are for Medicare Advantage (Part C) and Drug plan Changes (Part D).
-If you have opted for a Medicare supplement (Medigap plan), those have an open enrollment of 6 months from when you got your Part B, and in some states (like CA and OR), a recurring open enrollment around your birthday every year.-
If you have a Medicare Advantage plan, you can also make a one-time change during the first 3 months of each year (Jan 1 through March 31), called the Open enrollment for Medicare Advantage plans.
Lastly, you can change Medicare supplement plans from one plan to another whenever you want as long as you medically qualify. That is because they are medically underwritten policies. This will save you money if you switch from time to time (like care and home insurance). Finally, there are Special election periods for Medicare Advantage and Drug plans where you can change throughout the year due to special circumstances, and this is like if you moved or have a chronic condition.
All in all, call me Dave Boehm (Medicare Dave) so I can help you navigate this and get you into the right plan for you.
What is the maximum out-of-pocket limit for Medicare Advantage plans?
The federal government sets mandatory caps on out-of-pocket expenses for Medicare Advantage (Part C) plans. Once you reach this limit, your plan pays 100% of covered medical costs for the remainder of the year.Specific limits vary by plan, but federal guidelines enforce the following thresholds:
* IN-NETWORK SERVICES: The maximum limit is $9,250.
* COMBINED IN-NETWORK AND OUT OF NETWORK SERVICES: The maximum limit is $13,900.
Keep in mind these important details about the maximum out-of-pocket (MOOP) limit:
* LOWER LIMITS ARE COMMON: While $9,250 is the maximum allowed by the government, many individual plans voluntarily set much lower caps.
* AVERAGES: The average out-of-pocket cap is $5,421 for in-network services, and $9,825 for combined in-network and out-of-network services.
* WHAT COUNTS: Deductibles, copayments, and coinsurance for Part A and Part B covered services count towards this limit.
* WHAT DOES NOT COUNT: Your monthly plan premiums, prescription drug (Part D) costs, and extra supplemental benefits (such as dental, vision, or hearing) do not count toward your medical MOOP.
* PRESCRIPTION DRUGS: Part D prescription drug costs have a separate, dedicated annual out-of-pocket cap of $2,100.
To find out the specific MOOP limit for a plan you are considering, you can review its Summary of Benefits or compare options using the Medicare Plan Finder.
Do Medicare Advantage plans cover international travel?
Short answer: generally, no — and this surprises a lot of people.Most Medicare Advantage plans do not cover routine care outside the United States. If you get sick or injured while traveling internationally, you're largely on your own.
There are a few exceptions worth knowing:
Some plans offer emergency-only coverage in foreign countries — but it's limited, and you'll likely still have out-of-pocket costs
Certain Special Needs Plans (SNPs) may have different provisions depending on the carrier
Cruise ship coverage is a gray area — if the ship is in U.S. waters, you may have some coverage; once you're in international waters, probably not
Does Medicare cover SilverSneakers?
Voss Speros here, Greek god of Medicare. Medicare is all Greek to you? You're in luck, I'm Greek.
So the question today is: does Medicare cover SilverSneakers? Yes and no. Medicare Part A and B, original Medicare, does not cover SilverSneakers. No. But Medicare Advantage plans, a bunch of Medicare Advantage plans and some supplemental plans with extra benefits, do cover SilverSneakers or a gym membership type setup.
So they cover it at no cost to you. You go to the Advantage plans, it does cover SilverSneakers at no cost to you. You get access to thousands of gyms across the country, gyms in your area. Now, some gyms are in and some gyms are not. Some have a limited amount of participants in the gym, so just double check everything.
But yes, Advantage plans and some supplemental plans do offer that. Not original Medicare. If you want it, you've got to get an Advantage plan.
All right, have a good day. If you have any questions, let us know.
Why have millions of seniors suddenly lost their Medicare Advantage coverage?
That's a great question.Approximately 10% of Medicare Advantage enrollees were affected by plan terminations or carrier withdrawals this past year. The primary reason was that some insurance companies were losing money in certain markets and determined they could no longer offer those plans sustainably. Other carriers chose to reduce benefits, adjust service areas, or restructure their plans in order to remain in the Medicare Advantage market.
As a result, an estimated 2.9 million Medicare beneficiaries had to make a coverage change. Those affected generally had two options: enroll in a different Medicare Advantage plan or return to Original Medicare and, if eligible, enroll in a Medicare Supplement (Medigap) plan and a prescription drug plan.
This situation highlights the importance of reviewing your coverage each year. Medicare Advantage plans can change annually, including premiums, copays, provider networks, prescription drug coverage, and extra benefits. What worked well last year may not be the best fit this year.
Does moving to a new state let me switch from Medicare Advantage to Medigap without health questions?
Moving to a new state opens a Special Enrollment Period (SEP) for your move where you can switch with what's called . The moving process is a bit involved. First, you will need to stop your Advantage Plan and go back to Original Medicare. Once you are back in Original Medicare, you can apply for a Medigap Plan.Keep in mind that moving from Medicare Advantage to Medigap does not cover prescriptions. You will need to add a separate Prescription Drug Plan (Part D) with your Medigap Policy. Don't forget to check and see if your medications are covered.
You’ll have up to two months to get a Part D prescription plan, and you’ll qualify for a Medigap guaranteed issue period that lasts up to 63 days after your Medicare Advantage coverage ends. During this time, you can purchase most Medigap plans regardless of existing health problems.
Although the Medigap Plans offer the same coverage, premiums are not the same price. Also, different sates have their own rules for Medigap policies. For instance, New York, Connecticut, and Massachusetts offer enrollment at anytime, without the need for a Special Enrollment Period. Check with a licensed Medicare Broker in your new home town to help you with the specific rules in your new hometown.
Do doctors prefer Medigap or Medicare Advantage plans?
Most doctors that I talk with prefer their clients to have Medigap. It's easier for them from a billing standpoint, and they don't have to constantly wait for pre-approvals before they can provide care. With Medigap, they know that if Medicare pays, the Medigap plan is going to pay as well so they can recommend treatments with confidence.I’m on Humana Medicare. Customer service pre-approved a nuclear stress test, but I just got a $780 bill. They escalated it over a week ago and never called back. Do I have to pay? How do I file a complaint?
Call the Customer Care number on the back of the Humana member ID card. Or, you may file an appeal online at HUMANA. Make sure you have the following information.Humana ID card
Provider bill
Humana EOB
Date of service
Claim number
Provider name and NPI, if available
Amount billed
What the client believes is wrong
Any notes from calls with Humana or the provider
Make sure to indicate that it is an appeal of payment or a coverage decision.
If HUMANA can't resolve the issue, you can call 1-800-MEDICARE. Tell Medicare you have already filed the billing complaint with HUMANA, it has not been resolved to your satisfaction, and you would like to know what your next steps are.
Do Medicare Advantage PPO plans require referrals to see specialists?
Generally, no. Most Medicare Advantage PPO plans do not require referrals to see specialists. However, it's always important to verify that the specialist is in the plan's network if you want the lowest out-of-pocket costs, since PPO plans usually allow you to see both in-network and out-of-network providers at different cost levels.Does my Medicare Advantage plan cover me when I travel to another state?
You’re covered for emergency and urgent care anywhere in the United States at your plan’s copays. Going on a trip across the country, this is what most people are concerned with. In or out of network, your plan covers you nationwide for emergencies and urgent care.Some HMOs have a travel benefit where you can see a doctor for a non-emergent issue as long as that doctor is in their nationwide network. Outside of the network, you’ll pay full price.
PPOs will generally allow you see a doctor in a different state (in or out of network) for non-emergent issues, albeit generally at a higher copay than in your home region. People who spend much of the year in a different state (primary residence in Michigan, winter home in Arizona, for example) will choose a PPO for just that reason since they may be in one place long enough to need to see a doctor outside of an emergency setting.
Check your Summary Of Benefits or Evidence Of Coverage document (usually available on your provider’s website) for the details about your specific plan, or ask your agent to help you work through those details.
What is the biggest coverage gap most people don't know about with a Medicare Advantage plan?
The biggest coverage gap in Medicare Advantage plans is the costs for a hospital stay. Though there is a maximum out of pocket on what one will pay in a year, many Medicare beneficiaries are not prepared for the per day costs they would incur if they were hospitalized or the post-release care if they need additional institutional care. Having a hospital indemnity plan can help cover costs for the hospital stay; long term care coverage or tapping into the living benefits of a life insurance policy (if the policy has them) can help with post-release institutional care.
What's your go-to strategy for helping someone decide between Medicare Advantage and Medigap?
I simplify the plans by framing the choice as pay now or pay later. Medigap means paying a higher monthly premium for predictable, zero-stress medical bills and robust coverage. Medicare Advantage offers a low monthly premium but you pay as you go when you see a doctor or have a hospital stay - often with surprise bills.To find the right fit, we look at your budget, travel plans (are you a snowbird?), and whether you want total freedom seeing any doctor that accepts Medicare or don't mind staying in a local network. I also make sure you understand that turning 65 is the one time you can get a Medigap plan without underwriting. Switching down the road isn't always guaranteed if your health changes.
Finally, we plug your actual doctor list and prescriptions into our comparison tool to get a side-by-side comparison to confidently make your own choice.
I've heard Medicare Advantage plans have hidden costs. How do I know what I'm really getting?
No, there should not be any hidden costs in your Medicare Advantage plan. All copays, coinsurance, deductibles, and other cost-sharing are outlined in the plan's Summary of Benefits (SOB), which every plan is required to provide.To fully understand what you're getting, it's also important to review the plan's Evidence of Coverage (EOC), which provides detailed information about your benefits, coverage rules, and out-of-pocket costs.
Where confusion sometimes arises is with the cost-sharing of the supplemental benefits such as dental, vision, and hearing coverage. While these benefits are included in many plans, they often have coverage limits, copays, coinsurance, or annual maximums that aren't always understood.
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