Medicare Questions & Answers: The Medicare System
The Medicare System Q&A
Showing 222 questions
What are the reasons why I should work with a Medicare agent?
Working with a licensed Medicare agent offers more than just help picking a plan — it provides peace of mind. Here’s why:Trust: A good agent works in your best interest, not the insurance company’s. They build long-term relationships based on honesty, transparency, and dependability — so you always have someone in your corner.
Expertise: Medicare is complex. Between Original Medicare, Medicare Advantage, Supplements, and Part D drug plans — plus the yearly changes — a seasoned agent stays current and cuts through the confusion for you.
Personalized Guidance: Your health needs, medications, and doctors are unique. An agent takes time to understand your situation and recommends plans that fit you — not a one-size-fits-all solution.
Time-Saving: Instead of spending hours researching plans or navigating enrollment forms, your agent does the heavy lifting. That means fewer headaches and less chance of costly mistakes.
No Cost to You: Medicare agents are compensated by the insurance companies, not you. Their help is free — whether you enroll through them or not — so there’s no reason not to take advantage of the support.
Annual Reviews: Your health needs and plan options can change each year. A great agent checks in with you before the Annual Enrollment Period to ensure your coverage still works for you.
Help When You Need It: If a claim gets denied, your doctor switches networks, or you have billing issues — you’re not on your own. You have a trusted professional to call.
Local Knowledge & Carrier Access: Independent agents often represent multiple carriers, so they aren’t tied to just one company. They can compare plans across the board and help you find the best value based on what's available locally.
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.
What benefits are there to working with a Medicare Agent near me vs remote/virtual?
There are benefits to both but below will highlight benefits of working with Agents Near you:- Personalized Face-to-Face Interaction
* In-person meetings allow for clearer communication, especially for complex Medicare topics
* Body language and visual cues helps ensure you truly understand your options
* Easier to build trust and rapport though face-to-face interactions
- Local Market Knowledge
* Familiarity with local healthcare providers, hospitals, and specialists in your network
* Understanding of regional Medicare Advantage plans that might be specific to your area
* Knowledge of local community resources and support services
- Immediate Assistance
* Ability to meet on short notice when urgent issues arise
* Can help with physical paperwork and documentation in person
* No technology barriers or internet connection issues
- Community Connection
* Often involved in local senior events and educational seminars
* May have established relationships with local healthcare providers
* Can provide references from other clients in your community
Who can help me figure out this Medicare "maze and alphabet soup" it's so confusing.
Hi, so the question is who can help me figure out this Medicare maze of alphabet soup? It's very confusing. That would be me, Nolan Popel from the Popel Insurance Group. So yes, there are a few letters we want to make sure that we're familiar with when we're going on.
Medicare Part A is for the hospital. That's what we get for working our whole life and paying taxes. The first reason we get insurance is that Medicare doesn't cover everything. They do have a big deductible this year. It's $1,676 for these one through sixty.
Medicare Part B is your outpatient medical. Medicare Part B is what you're gonna be signing up for when you first turn 65 or you're retiring from your group coverage from an employer or a spouse's employer. Part B in 2025 is going to cost you $185 a month. That's for Uncle Sam. That is for the government to pick up 80% of your outpatient medical bills, and you're paying 20%. This is a primary reason people look for insurance because they don't want to get stuck paying huge bills for 20%.
See, like Charlie is what we call the Medicare Advantage program. These are HMOs and PPOs that are subsidized by the federal government. And then we have Part D, like David. Part D is also very important. This is the term for the Medicare prescription drug program. We can get Part D in a couple of different ways. We can buy a standalone Medicare prescription drug plan, or we can get a Medicare Advantage plan that comes with Part D along with it, kind of like a package deal where you get medical and prescriptions together.
A couple more letters that I'd like to mention to you are G, like George, and N, like Nancy. These are two very popular Medicare supplement options in the United States that you can definitely look into when you get to the point of looking for insurance.
I don't understand how my friend pays nothing for their plan and I pay over $200-are these plans just totally random by ZIP code?
I love this question because it shows something really important about Medicare and how it actually works, and that is that it's not one size fits all.
The short answer is no, it's not random. There's always an answer to why someone's paying nothing and you're paying a lot more. Here's just a few of them.
Your friend might be on a Medicare Advantage plan and you might have a Medicare Supplement. Medicare Advantage plans have little to no premium, and you pay as you go. For Medicare Supplement, you're paying a high monthly premium, usually over $200 a month, and it gives you basically 100% coverage. So even if they're paying nothing, they may end up paying more than you if they have to use their insurance a lot.
They also may not know how much they're even paying. I've met a ton of people who thought they weren't paying for Medicare, but it turns out they're drawing $202.90 a month out of their Social Security check before they even get it.
But the most common reason I see is because they have Medicaid, which is a state program that's income based, and it can pay for all their premiums and all their health coverage. Not everybody qualifies. You have to be below a certain income.
So many people assume they can't qualify for things based off their zip code because that's what the commercials tell you. That just shows you what plans are available in your area or your county. Your income is what determines a lot of times what things you can qualify for.
But regardless, no two situations are alike. Don't make your decision based on what your friend has. Make sure to reach out to a broker who can help you determine what plan is going to be best for your specific situation.
I lost my Medicare Card. What do I do?
Don’t panic because losing your Medicare card is more common than you might think and it can be replaced.If you have an online My Social Security account, you can log in at ssa.gov to request a replacement card or print an official copy right away. If you don’t have an account yet, you can create one in just a few minutes.
You can also call Social Security directly at 1-800-772-1213 (TTY: 1-800-325-0778) to request a new card by mail.
While you’re waiting for your replacement, most doctors and pharmacies can still look up your Medicare coverage using your Social Security number. If you’re enrolled in a Medicare Advantage or Part D plan, you can continue using your plan’s member ID card.
To protect yourself, avoid carrying your Medicare card unless you need it and never share your Medicare number with unsolicited callers.
If you need help accessing your information or have questions about your coverage, a licensed, independent agent can help guide you every step of the way.
I went to a free Medicare seminar and it felt like a timeshare pitch. Are any of those events actually helpful?
Some are helpful, but a lot of them are really lead-generation events dressed up as education. The useful ones focus on explaining Medicare basics, enrollment timelines, penalties, Medigap vs. Medicare Advantage, Part D, and how to compare options; the less useful ones spend most of the time steering people toward one plan, one carrier, or setting a one-on-one appointment. A good rule is this: if the event feels balanced and educational, it may be worth attending, but if it relies on pressure, fear, “limited-time” language, or pushes you to enroll before you’ve had time to compare your choices, treat it like a sales pitch.
Can you help me understand Maximum Out-of-Pocket (MOOP) limits in Medicare plans, from your experience as an agent?
The Maximum Out-of-Pocket (MOOP) limit is the highest amount of money you will have to pay for covered healthcare services in a Medicare Advantage plan during a given year. Once you hit this limit, the plan will pay 100% of your covered medical expenses for the rest of the year. This includes deductibles, copayments, and coinsurance, but it does not include things like premiums or non-covered services (like cosmetic surgery or out-of-network care).Let’s say someone’s Medicare Advantage plan has a $5,000 MOOP. If that person receives treatment for a chronic condition and their total out-of-pocket costs for things like doctor visits, tests, and hospital stays reach $4,800, they’ll only need to pay $200 more for the rest of the year. After that, the plan would cover all additional costs for the year, even if more treatments are needed.
The MOOP is a safety net for Medicare Advantage beneficiaries, protecting them from potentially high medical costs in any given year. It’s important to compare the MOOP limits of different plans when selecting coverage, as a higher premium plan with a lower MOOP might be better for someone with frequent healthcare needs, while a plan with a higher MOOP and lower premiums could suit someone who is generally healthy.
It’s a balancing act between premiums, MOOP, and overall healthcare needs that will vary depending on the individual!
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.
I've been on disability for years and am about to turn 65. Do I automatically get Medicare because I'm on Social Security, or do I need to do something?
People who have drawn Social Security Disability (SSDI) for at least 2 years are eligible for Medicare even BEFORE turning 65. Enrollment generally occurs in the 25th month of receiving SSDI, usually providing Parts A and B automatically. To be eligible for Part A at no additional cost you must have worked full time in the USA for at least 10 years. If you have NOT drawn SSDI for at least 2 years then you can enroll in Medicare anytime in the 3 months before your 65th birthday month, and up to 3 months after. If you don't enroll in a timely manner then there could be lifetime penalties assessed to your premiums. If you're still confused that's what I'm for, I'd be happy to guide you through the process.Exceptions: The 24-month waiting period is waived for those with Amyotrophic Lateral Sclerosis (ALS) or End-Stage Renal Disease (ESRD)
I picked the plan with the lowest premium, but now every doctor visit feels like a surprise bill. Should I have gone with a higher premium instead?
Here's what nobody tells you when you're picking a plan: the premium is only one piece of the puzzle, and it's often the smallest piece if you actually use your coverage.A lower premium usually means the plan is shifting more of the cost to when you actually see a doctor — through higher copays, coinsurance, or a bigger deductible before coverage kicks in. So it's not that you made a "wrong" choice, it's that premium alone doesn't tell you what a plan will actually cost you over a full year of visits.
The number that matters more is the total out-of-pocket maximum — the most you could pay in a worst-case year, copays and all — plus what a typical visit or prescription actually costs you under that specific plan.
A plan with a slightly higher premium sometimes ends up cheaper overall if you see doctors regularly, because it caps your exposure lower. The good news is this isn't permanent — you get a chance to re-shop every year during open enrollment. I highly recommend that you engage an independent agent like myself who will compare the whole cost picture, not just the monthly number.
My friend lives in a different city and has a much more detailed Medicare plan. Is their plan dependent on their location?
Hi there. It depends. If your friend has Original Medicare and a Medicare Supplement (Medigap), then she can go anywhere in the U.S. that accepts Medicare. If however, your friend has "detailed plan", it sounds like an Advantage plan. If it an HMO, she must stay in her local organization of doctors. Many of the PPO Advantage plans will now allow you to go to another doctor in a different city, as long as it is still in that insurance carriers network. If she has Aetna PPO, for example, she can often find in network Drs away from home.With that said, all Advantage plans cover emergency care out of network.
If your friend is traveling and has an emergency, her insurance will usually cover out of network, but if she is moving... she will either want Medigap plan G/ N or change Advantage plans to her new location.
I hope this helps.
Every year I stress over picking a plan and still end up surprised by the bills. Is there any way to just get peace of mind with Medicare?
You're definitely not alone—Medicare can feel overwhelming, and it’s incredibly frustrating to try to make the “right” choice each year only to be hit with surprise bills anyway. The good news is: yes, there is a way to get peace of mind, but it depends on what peace of mind looks like for you.Ask Yourself: What Does Peace of Mind Mean?
Predictable costs?
Freedom to see any doctor?
No need to switch plans every year.
Extra benefits like dental and vision?
Once you define what matters most, you can build your Medicare around that.
Here Are 3 Paths to Peace of Mind with Medicare:
1. Original Medicare + Medigap Plan G
Fixed, predictable costs: Only pay the Part B deductible ($240 in 2024), then Plan G covers the rest
See any doctor in the U.S. who takes Medicare—no networks, no referrals
Doesn’t change year to year like Medicare Advantage plans
Best for people who want stability and maximum coverage with no surprises
2. A Strong Medicare Advantage PPO Plan
Includes medical, hospital, and usually drug coverage in one plan
Often $0 premium with added benefits (dental, vision, hearing, gym)
Some offer nationwide access (PPO), but you may pay more out-of-network
Best if you’re healthy, want extras, and prefer simplicity in one plan
3. Work with a Trusted Medicare Agent Every Year
Instead of trying to do it alone, a good agent will:
Compare all available plans in your ZIP code
Make sure your doctors and prescriptions are covered
Help you avoid hidden costs and coverage gaps
Best if you want expert help and hate doing all the research yourself
Bottom Line:
Yes, peace of mind is possible—you just need a strategy that matches your lifestyle, and ideally, a guide you trust to help you through it each year.
Would you like help reviewing your current setup and seeing if there’s a more stable, lower-stress option for you?
Contact us for help
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.
What do I do if I cannot afford my Medicare premiums?
💙 1. Medicare Savings Programs (MSPs)These state-run programs can help pay for:
• Part B premiums
• Sometimes Part A premiums
• Deductibles and coinsurance (depending on the program)
The main programs include:
• QMB (Qualified Medicare Beneficiary)
• SLMB (Specified Low-Income Medicare Beneficiary)
• QI (Qualifying Individual)
Eligibility is based on income and limited assets.
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💊 2. Extra Help (Part D Low-Income Subsidy)
The Extra Help program helps pay for:
• Prescription drug plan premiums
• Deductibles
• Copays
You apply through the Social Security Administration, and many people qualify without realizing it.
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🏥 3. Medicaid
If your income is very limited, you may qualify for both Medicare and Medicaid (often called “dual eligible”). Medicaid can help cover premiums and additional medical costs.
You apply through your state Medicaid office.
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📌 4. Contact Social Security
If you’re having trouble paying premiums that are being deducted from your Social Security check — or you’re being billed directly — contact the Social Security Administration right away to avoid losing coverage.
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✅ Key Takeaway
If you cannot afford your Medicare premiums, do not ignore the bills. Help is available — and many assistance programs are income-based, not credit-based.
I live in California but might move to another state next year. How will my Medicare coverage change if I relocate?
Here’s exactly how your Medicare coverage changes — and one unique opportunity many people miss:*Original Medicare (Parts A & B)
No change — It follows you anywhere in the U.S.
You can see any doctor or hospital that accepts Medicare nationwide.
Your Medicare card stays the same.
*Medigap (Supplement)
Your current policy moves with you nationwide.
Just notify your insurance company of the new address.
Premiums may go up or down based on the new state/zip code.
*Medicare Advantage (Part C) or Part D Drug Plan
These are local plans — most won’t work in your new state.
You’ll need to switch during your Special Enrollment Period (see below)
If you notify your current plan before you move: Your SEP starts the month before your move month and continues for 2 full months after you move.
If you notify your plan after you move: Your SEP starts the month you notify them and runs for 2 full months after that.
🚨 This is a BIG Opportunity If You’re on Medicare Advantage
If you have a Medicare Advantage plan and you’re moving out of its service area, this move gives you Guaranteed Issue (GI) rights for Medigap.
That means you can drop your Advantage plan and buy a Medigap policy WITHOUT medical underwriting — that means no health questions and no denials, even if you have pre-existing conditions.
This is one of the rare second chances to switch to Medigap penalty-free. Many people use a planned move exactly for this reason.
So with all these 2025 Medicare changes, should I be switching plans or staying put?
This is a good question with not enough space for me to answer.Also, I am not sure if this was a question from last year for the 2025 year. If so, there were changes to where the coverage gap or "donut hole" was eliminated with the 2025 prescription drug plans having a maximum out of pocket instituted of $2000. Also, the MP3 option was implemented which was the Medicare Prescription Payment Plan allowing Medicare Beneficiaries who may have high cost medications to spread their payments over the annual year to make it easier for budgeting purposes.
For 2026, the maximum out of pocket limit will be increased to $2100 for prescription drug plan costs.
If referencing changes from 2025 to 2026, there have been a lot of changes in the Medicare market.
Many insurance carriers (not all) have reduced their footprint in the Medicare Advantage plan market across the U.S. A small portion of insurance carriers have increased their footprint.
Also, there is a move from PPO plans being eliminated or reduced, and many of the major insurance carriers are changing their focus to HMO plans within the Medicare Advantage market.
In addition, there was a VBID or Value Based Insurance Design model that was implemented in 2017 for Medicare Advantage Plans. This will end on December 31, 2025. This decision was made by CMS (Centers for Medicare and Medicaid Services) due to substantial costs within the program. What this means is that a lot of the benefits needed to be revisited by insurance carriers. Insurance carriers may have eliminated or reduced benefits or have switched their focus to benefits that Medicare beneficiaries tend to prioritize over other benefits. Many plans with similar benefits have switched focus to Special Supplemental Benefits for the Chronically Ill or SSBCI model. With this option, Medicare beneficiaries have to qualify to be in the plans and usually have 60 days to verify the chronic condition.
Plans should be reviewed annually.
How do you stay up to date with changes in Medicare policies and plan options each year?
Here’s how to stay current:Official CMS Sources
• Medicare.gov and CMS — the ground truth for rule changes, premium announcements, and plan data
• CMS listservs — free email alerts straight from CMS when new guidance drops
• Medicare & You handbook — released each fall, covers all major changes for the upcoming year
Carrier & Plan Updates
• Annual Notice of Change (ANOC) letters — carriers send these to enrollees every September; read them, they flag what’s shifting
• Carrier portals and agent newsletters — most carriers push AEP updates directly to contracted agents
Industry Resources
• AHIP (ahip.org) — policy updates and compliance training
• Kaiser Family Foundation (kff.org) — deep data and analysis on Medicare trends
• Medicare Rights Center (medicarerights.org) — beneficiary-focused policy breakdowns
• NABIP — your professional association; they track legislative and regulatory changes
For AEP Specifically
• CMS releases the Annual Call Letter and Final Rule each spring — that’s your early warning system for what’s coming in the next plan year
• Plan comparison tools update on Medicare.gov every October 15
Peer Networks
• Facebook groups and forums for independent Medicare agents
• FMO/IMO newsletters and training calls — your upline should be pushing updates to you regularly
My friend said she got a free annual physical with Medicare, but my doctor billed me. What's going on?
Medicare covers a Wellness Visit at 100%, but it is not the same as a traditional physical exam. If your doctor performed anything beyond the Wellness Visit checklist, they can (and usually will) bill you.Here’s the difference:
Medicare Annual Wellness Visit (free)
Covered at 100%
Includes:
Health history review
Medication review
Height, weight, blood pressure
Cognitive screening
Preventive planning
No hands‑on exam. No labs. No tests.
Annual Physical (not free under Medicare)
Medicare does not cover this.
If your doctor:
Listened to your heart/lungs
Checked reflexes
Ordered labs
Addressed new symptoms
Managed chronic conditions
…that becomes a billed service, and you may owe a copay or coinsurance.
You didn’t do anything wrong; Medicare’s terminology is confusing.
This is exactly why I walk clients through what’s covered, what isn’t, and how to avoid surprise bills. Having your own Medicare agent who really clarifies these details can make all the difference.
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.
What's an underrated benefit of Original Medicare that many people overlook?
One of the most underrated benefits of Original Medicare is the freedom to see any doctor, specialist, or hospital in the country that accepts Medicare without needing a referral or worrying about network restrictions. Most people do not fully appreciate this until they need a second opinion from a specialist at a major medical center like Mayo Clinic or Cleveland Clinic, and they can simply go without asking anyone's permission. Another overlooked benefit is the Welcome to Medicare preventive visit and the annual wellness visit, which are covered at no cost and give you a dedicated opportunity to build a health plan with your doctor each year. Original Medicare also gives you a level of stability that Advantage plans cannot always match, because your coverage does not change based on a carrier's annual network or formulary decisions. For people with serious or complex health conditions, that consistency and freedom of access can be worth far more than any extra benefit an Advantage plan advertises.
An agent asked me to sign a scope of appointment for before we could discuss my Medicare insurance or part D plan. What is an SOA? Is this normal? Are call centers exempt from this practice?
The Scope of Appointment (SOA) form is required to be signed 48 hours prior to any scheduled appointment where Medicare Prescription Drug (Part D) plans or Medicare Advantage (Part C) plans benefits are being discussed. The SOA lays out what will be discussed during your appointment with the agent/broker. Only plan types selected on the SOA can be discussed during your meeting. It must be signed by both the Medicare beneficiary and the Medicare agent/broker. The form is a Medicare requirement and all agents, included call center agents, are required to comply with the regulation.There are three exceptions to the 48 hour rule:
1) Walk in without prior appointment
2) Inbound call initiated by the beneficiary
3) Within 4 days of the end of a valid election period
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.
Can Medicare drop me for health reasons?
No, Medicare cannot drop you because of your health. If you have Medicare, your coverage continues even if you have health problems or develop a new illness.Original Medicare (Parts A and B) is a government health insurance program, so once you’re enrolled, you’re guaranteed coverage (assuming you remain eligible, such as by age or disability status).
The following are a few details to know:
Original Medicare (Parts A & B): You cannot be denied or dropped based on your health.
Medicare Advantage (Part C): These are private insurance plans, but they must accept anyone who’s eligible for Medicare and who lives in their service area, regardless of health. The only exception is for people with end-stage renal disease (ESRD) — until recently, plans did not have to accept those patients, but this has now changed, and nearly all plans accept ESRD.
Medicare Supplement (Medigap): When you first become eligible (your 6-month Medigap Open Enrollment Period), you’re guaranteed acceptance regardless of health. Outside that window, insurance companies in most states can ask health questions, but once they accept you, they cannot drop you as long as you pay your premiums.
In summary, while your plan options may vary based on when and how you apply, once you have Medicare coverage, the program cannot drop you for health reasons.
Can you just have A and B and not enroll in anything else and still have good coverage?
That’s a great question — and it’s one a lot of people ask when they first get on Medicare.Technically, yes — you can have just Medicare Parts A and B and choose not to enroll in anything else. However, it’s usually not enough coverage for most people. Here’s why:
Part A covers hospital stays, skilled nursing care, hospice, and some home health care — but you’ll still face a large deductible per hospital stay and daily coinsurance costs if your stay is extended.
Part B covers doctor visits, outpatient care, preventive services, and medical supplies — but it only pays 80% of approved costs, leaving you responsible for the other 20% with no cap on how high those bills can go.
That means if you have a serious illness, surgery, or long hospital stay, your out-of-pocket costs could be thousands of dollars.
That’s why most people add either:
A Medigap (Supplement) plan to cover the leftover 20% and hospital costs, or
A Medicare Advantage (Part C) plan, which combines A and B and often adds prescription, dental, and vision benefits.
So while you can stay with just A and B, it’s not recommended long-term if you want full protection and predictable costs.
Would you like me to explain how much you’d typically pay out of pocket if you kept only A and B?
What should I do if I miss the Medicare Open Enrollment period, and I want to change my plan?
If you miss the main Medicare Open Enrollment Period, you may still have options depending on your situation and the type of change you want to make.Main Enrollment Windows
Medicare Annual Enrollment Period (AEP)
October 15 – December 7
You can:
switch Medicare Advantage plans,
move from Medicare Advantage to Original Medicare,
join/change/drop Part D drug plans.
Coverage changes start January 1.
Medicare Advantage Open Enrollment Period (MA OEP)
January 1 – March 31
If you already have a Medicare Advantage plan, you can:
switch to another Medicare Advantage plan once,
or return to Original Medicare and add Part D.
You cannot switch from Original Medicare to Medicare Advantage during this window.
If You Missed Both
You may still qualify for a Special Enrollment Period (SEP).
Common SEP triggers include:
Moving to a new service area
Losing employer or union coverage
Medicaid eligibility changes
Qualifying for Extra Help
Moving into or out of a nursing facility
Plan termination by the carrier
FEMA or disaster-related issues
Gaining or losing a Special Needs Plan condition
Recently leaving incarceration
Centers for Medicare & Medicaid Services allows SEPs for many life events, but the rules and timelines vary.
Can you explain Special Needs Plans in Medicare?
A Medicare Special Needs Plan (SNP) is a specialized type of Medicare Advantage plan (Part C) that limits enrollment to individuals with specific diseases, or who are dually eligible for Medicare and Medicaid. These plans tailor their benefits, provider networks, and drug formularies to best meet the unique needs of their members.Three Primary Types of SNPs:
Dual Eligible Special Needs Plans (D-SNP): For individuals who qualify for both Medicare and Medicaid.
Chronic Condition Special Needs Plans (C-SNP): For individuals with specific, severe, or disabling chronic conditions (e.g., dementia, diabetes, end-stage renal disease).
Institutional Special Needs Plans (I-SNP): For individuals who live in a nursing home or require nursing care at home for 90 days or longer
I've heard about IRMAA affecting my Medicare premiums. How can I find out if it applies to me, and how does it work?
IRMAA is always (NOT) a fun surprise and many folks don’t see it coming. It stands for Income-Related Monthly Adjustment Amount, but really, it just means Medicare is charging you more because you “made too much” two years ago. Yay, right?Medicare looks at your income from two years back - so in 2025, they’re using your 2023 tax return. If your income was over a certain amount, you’ll pay extra for Part B and Part D. And no, it’s not always a small bump - it can be a few hundred bucks more per month depending on your income level.
You’ll get a letter from Social Security if IRMAA applies. The timing of that letter? Let’s just say it's government issued and doesn’t always conveniently show up BEFORE you’ve already picked your plans and thought you had your costs locked in.
If you’re not working with someone who brings this up ahead of time, that Social Security letter is not a fun one to open. That’s why it helps to trust your advisor who’s actually looking ahead - not just plugging in plan info or letting you go at it alone.
The good news? If your income has gone down if you just retired, sold a business, or lost a spouse - you can appeal it using form SSA-44 to get those premiums adjusted.
If your 2023 income was over $103,000 (single) or $206,000 (married filing jointly), it’s worth looking into. If not, you’re probably good. Either way, the key is catching it before you’re stuck wondering why your Medicare bill just jumped.
Are Medicare plans and requirements different for every state?
Medicare itself is regulated at the national level (CMS), so Medicare’s premiums, timelines, compliance rules, costs, requirements, enrollment periods, premiums, deductibles, rules & regulations are standardized nationwide.Medicare Supplements (Plan F, Plan G, Plan N & others) are also standardized nationwide, but a few states have rejected the standardized model and created their own unique model of Medicare Supplement that has its own set of coverages.
Medicare Prescription Drug Plans (Part D) and Medicare Advantage Plans, while being heavily regulated by CMS to follow strict guidelines, are service-area specific, and vary across the insurance companies who are contracted with Medicare.
The “service areas” are counties, and then differentiated again per state. Each insurance company must align with Medicare rules, but is allowed to provide additional benefits and services above the Medicare model.
Part D coverage is a Medicare requirement (with a penalty for going without it), but is provided by insurance companies, not Medicare itself.
Medicare plans change once per year January 1, and are available for agents and beneficiaries to see every October 1, with enrollments allowed into the following year’s plans October 15 - December 7.
In reviewing your Medicare coverage options and education, you can consult the Medicare & You Guidebook that is mailed to all Medicare beneficiaries, available on Medicare.gov. It’s also important to become aligned with an agent or broker who has been certified by CMS and contracted to represent plans *compliantly* with Medicare’s rules and regulations. Make sure they know their stuff!
I tried calling Medicare and got transferred five times. Is there any way to get straight answers from them?
To get straightforward answers from Medicare, try initiating your own call to 1-800-MEDICARE or using the secure online portal on Medicare.gov. You can also explore the online resources and consider contacting a SHIP (State Health Insurance Assistance Program) counselor for personalized guidance.Elaboration:
Initiate Your Own Call:
Instead of waiting for calls, call Medicare directly at 1-800-MEDICARE.
Secure Online Portal:
Explore the secure online portal on Medicare.gov for information and to manage your account.
Online Resources:
Review Medicare.gov for answers to common questions, including how to enroll, understand coverage, and handle appeals.
SHIP Counseling:
Consider contacting your local SHIP counselor for personalized assistance, as they can provide unbiased information and guidance.
Report Unwanted Calls:
If you are receiving unsolicited calls claiming to be from Medicare, report them to the Federal Communications Commission (FCC) or the Federal Trade Commission (FTC).
I'm healthy and barely use my coverage, but I'm still paying more every year. Why isn't there a discount for people like me?
Why There’s No Discount for Being “Healthy”Medicare is community-rated: Especially for Part B and many Medigap plans, premiums are set based on broader risk pools—not your individual usage. Everyone pays in to help cover the collective cost of care, regardless of how often they use services.
Healthcare costs are rising: Annual increases in premiums, deductibles, and drug costs are tied to inflation in healthcare spending, not personal health.
Preventive focus: Medicare’s goal is to encourage preventive care and catch issues early—even for those who feel healthy now—so the system still encourages regular check-ins and coverage.
What You Can Do
Even though there’s no official discount for being low-risk, here are some smart strategies:
Consider a high-deductible Medigap plan (like Plan G High Deductible): You pay less in premiums and only pay more if/when you need care.
Look into Medicare Advantage (Part C) plans: Many offer low or even $0 premiums and may fit your needs if you rarely visit the doctor—but make sure to understand network and cost structures.
Review your drug coverage yearly: If you don’t take many prescriptions, you might be overpaying for a Part D plan.
Check for programs or rebates: Some Advantage plans offer “give-backs” or reimburse a portion of your Part B premium—great for low-utilizers like you.
Steven Graves
If I need hospice care in the future, can my Medicare plan cover it?
Yes, Medicare (.gov) covers hospice care for those who are terminally ill and meet specific eligibility requirements. Both Original Medicare (Part A and Part B) and Medicare Advantage (Part C) plans cover hospice care. If you have Medicare Part A, are certified by your doctor as terminally ill with a prognosis of six months or less, and choose hospice care over curative treatment, Medicare will cover the costs associated with your hospice care.Here's a more detailed explanation:
Eligibility:
To be eligible for Medicare hospice benefits, you must have Medicare Part A, be certified as terminally ill by your doctor with a prognosis of six months or less to live, and choose hospice care instead of curative treatment.
Coverage:
Once you're eligible, Medicare will cover the costs associated with hospice care, which includes a wide range of services like medical care, skilled nursing, personal care, counseling, social services, and respite care.
Medicare Advantage:
Even if you have a Medicare Advantage plan, Original Medicare (Parts A and B) will still cover hospice care if you meet the eligibility requirements.
Cost:
There is no deductible for hospice care under Medicare, and you will not need to pay a co-payment for the services you receive. You will, however, need to continue to pay your monthly Medicare Part A and Part B premiums.
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.
Can I enroll in Medicare if I've never paid into Social Security due to working overseas?
If you are a US citizen or lawful permanent resident (with 5+ years of residency) you CAN enroll in medicare, but your cost will likely be different if you’ve never paid into the system.Part A is premium free if you’ve worked for 40 quarters (10 years) and paid into the system. If you don’t meet that requirement, you can BUY part A coverage.
Part B would be handled the same as everyone else - you’ll pay the premium appropriate for your income.
Your supplemental coverage (Medicare Advantage, Medigap and/or Part D) are based on your medicare eligibility and not based on your social security contributions.
NOTE - Foreign work credits from countries with TOTALIZATION agreements with the US (ie Canada, the UK, Germany) MAY count toward the Social Security eligibility and COULD reduce or eliminate the Part A premium. Also, if you’re married to someone with US Work Credits that can make a difference, so there are a lot of variables to this situation. Social Security can help you determine what comes next.
I've been paying into Medicare for years, and I'm not sure why my specialist visits still cost me so much. What am I missing here?
What usually surprises people is that Original Medicare isn’t designed to cover everything—it’s more of a cost-sharing setup.Under Part B, you generally pay:
• The annual deductible
• Then 20% coinsurance for specialist visits, tests, and procedures
• And there’s no cap on what you could spend out of pocket
So if your specialist bills $300, you’re on the hook for about $60 every visit—and that adds up quickly.
What most people are “missing” is that Medicare was built to be paired with either:
• A Medigap (supplement) to cover that 20%, or
• A Medicare Advantage plan that replaces the 20% with set copays and includes a max out-of-pocket
If you only have Original Medicare by itself, what you’re experiencing is exactly how it’s structured to work.
My husband passed away and now my Medicare premiums went up. Why does losing someone raise your costs?
It's understandable to feel frustrated & confused when your Medicare premiums increase after the passing of your husband. Here's why this might happen:Income-Related Monthly Adjustment Amount (IRMAA): Your Medicare Part B and Part D premiums are determined, in part, by your income. After your husband's death, your income may change, potentially shifting you into a different income bracket & affecting your Income-Related Monthly Adjustment Amount (IRMAA).
Change in Tax Filing Status: When your husband passed away, your tax filing status changed from "married filing jointly" to "single" in the year following his death. This can impact your Modified Adjusted Gross Income (MAGI), which is used to calculate your IRMAA.
Income Thresholds: There are different income thresholds for single filers versus those married filing jointly, & the loss of your husband's income might put you above the threshold for the higher IRMAA, even if your income decreased overall.
Loss of Spousal Discounts: If you had a Medicare Supplement plan & were receiving a spousal discount, this discount would no longer apply after your husband's passing, leading to an increase in your premium.
Increased Healthcare Needs: A study published in the National Institutes of Health (NIH) indicates that spousal death can lead to increased healthcare costs & usage for the surviving spouse, which may influence your Medicare premiums in some ways.
What you can do:
Contact Social Security: You can contact the Social Security Administration to discuss your situation & see if your new income level might qualify you for a reduced IRMAA.
Appeal IRMAA: You can appeal your IRMAA determination if you believe it is incorrect.
Review Your Medicare Plan: It's important to review your current Medicare coverage & consider your options.
Consult a Financial Advisor: A financial advisor specializing in retirement planning can help you understand how losing your husband might impact your Medicare costs & guide you.
Does IRMAA go away automatically if my income drops, or do I need to report it to Social Security?
IRMAA does not go away automatically — but the good news is that Social Security does review it every year using your most recent tax data on file, so it can drop on its own without you doing anything, depending on the timing.Here's how it works:
The automatic annual review. Each year, Social Security redetermines your IRMAA surcharge using your tax return from two years prior (so your 2026 IRMAA is based on your 2024 income). If your income naturally fell in that prior year and it's already reflected in the IRS data SSA pulls, your IRMAA will simply be lower or gone when the new year starts — no action needed.
When you should proactively report it. If your income dropped more recently — say in 2025 or 2026 — SSA won't automatically know about it yet because they'd still be looking at older tax data. In that case, you can (and should) request a reconsideration using form SSA-44. The qualifying life-changing events that allow you to appeal early include retirement or reduction in work hours, marriage, divorce or annulment, death of a spouse, loss of income-producing property, loss of pension income, and employer settlement payments.
The process. You file the SSA-44 with Social Security, provide documentation of the income change (like a letter from your employer, or evidence of retirement), and they'll use your more recent estimated income instead of the two-year-old figure. If approved, the lower premium kicks in relatively quickly.
One thing to watch for. If you appeal based on estimated future income and your actual income ends up higher, SSA can come back and collect the difference — so it's best to be conservative in your estimate.
The bottom line: if the income drop already shows up in a tax return SSA has on file, it'll likely resolve itself at the start of the next calendar year. If it's a recent change, filing the SSA-44 is the way to get faster relief.
What role do you think technology will play in the future of Medicare?
Technology will play a major role in making Medicare more accessible, efficient, and personalized by:Expanding telehealth, especially for rural and mobility-limited seniors
Using data and AI to better manage chronic conditions and prevent hospitalizations
Improving care coordination through electronic records and remote monitoring
Simplifying enrollment and plan management with better online tools
The challenge will be ensuring older adults can easily use the technology—not just that it exists.
Is my Medicare deductible supposed change from year to year?
Yes — your Medicare deductible can change from year to year, and it usually does. The amounts are set annually by the Centers for Medicare & Medicaid Services (CMS) and often increase slightly to keep up with inflation and rising healthcare costs.Here’s a quick breakdown:
Medicare Part A (Hospital Insurance)
Covers inpatient hospital stays, skilled nursing, hospice, etc.
The Part A deductible typically increases each year. For example:
In 2024, it was $1,632 per benefit period.
For 2025, CMS announced it will be $1,688 per benefit period.
This deductible applies per benefit period, not annually — meaning you may owe it more than once in a year if you have multiple hospital stays separated by more than 60 days.
Medicare Part B (Medical Insurance)
Covers doctor visits, outpatient care, and other medical services.
The Part B deductible also adjusts yearly:
In 2024, it was $240.
For 2025, it’s set to rise to $257.
You pay this once per year, then Medicare typically covers 80% of approved services after that.
Medicare Advantage (Part C) and Part D (Prescription Drug Plans)
These are private plans, so their deductibles and copayments can change each year as well.
Insurers are required to notify you of changes in their Annual Notice of Change (ANOC) each fall.
Why am I paying more for Medicare Part B and D than my friends? What is IRMAA and how is it calculated?
IRMAA stands for the Income-Related Monthly Adjustment Amount. It's an additional premium some people pay for Medicare Part B and Part D if their income is above certain limits.Medicare looks at your Modified Adjusted Gross Income (MAGI) from your federal tax return filed two years earlier. For example, your 2026 Medicare premiums are generally based on your 2024 tax return.
* Your friends may pay less because their income falls into a lower IRMAA bracket.
* IRMAA is recalculated each year based on the most recent tax information available.
* If you've experienced a life-changing event—such as retirement, marriage, divorce, or the death of a spouse—you may be able to request a reduction by filing Form SSA-44 with the Social Security Administration.
If you're unsure whether your IRMAA is correct, I'd be happy to help you determine which income bracket you fall into and whether you may qualify for an adjustment.
2026 IRMAA income brackets
Higher income results in higher Medicare Part B and Part D premiums. Based on 2024 tax returns for individuals.
income level
≤ $110k 1
$110k–$138k 2
$138k–$172k 3
$172k–$206k 4
$206k–$550k 5
>$550k 6
Can you explain what "creditable coverage" means and when it applies?
Absolutely—this term causes a lot of confusion, and it means different things depending on the situation. Let’s make it clean and practical.⸻
What “Creditable Coverage” means (plain English)
Creditable coverage is health or drug coverage that Medicare considers “good enough” so you’re not penalized when you enroll later.
It mainly applies in two specific Medicare contexts:
1. Medicare Part B (medical)
2. Medicare Part D (prescription drugs)
Outside of those, the word gets misused a lot.
⸻
1. Creditable Coverage for Medicare Part B
This applies when you delay Part B.
Creditable coverage for Part B =
• Active employer group health coverage
• From current employment (yours or your spouse’s)
• Usually from an employer with 20+ employees
Why it matters
If you have this kind of coverage:
• You can delay Part B without penalty
• You qualify for a Special Enrollment Period (SEP) later
What does NOT count for Part B
❌ COBRA
❌ Retiree coverage
❌ Marketplace (ACA) plans
❌ VA coverage (for Part B purposes)
❌ Medigap or Medicare Advantage
Only current, active employer coverage counts here.
⸻
2. Creditable Coverage for Medicare Part D
This is the most common use of the term.
Creditable drug coverage means:
• Prescription coverage that is at least as good as a standard Medicare Part D plan
Examples that often count
✅ Employer or union drug plans
✅ VA prescription benefits
✅ TRICARE
✅ Some retiree plans
Each year, the plan must send a Creditable Coverage Notice telling you whether it qualifies.
Why it matters
If you go:
• 63 days or more without creditable drug coverage after Medicare eligibility,
• You can get a lifetime Part D penalty
⸻
3. What “creditable coverage” does NOT mean
This is the key misunderstanding:
🚫 Creditable coverage does NOT automatically:
• Give you Guaranteed Issue rights for Medigap
• Replace Medicare
• Mean you can enroll anytime
What are the 6 things Medicare doesn't cover?
❌ 1. Long-Term Care (Custodial Care) Such as nursing homes, assisted living, or help with bathing, dressing, and eating. Medicare covers short-term rehab, not ongoing personal care.❌ 2. Dental Care (Ask me for good PPO dental) Medicare Advantage plans have preventative dental cleanings x-rays and annual visits, but Original Medicare does not.
❌ 3. Vision Care. No routine eye exams, glasses, or contacts. Some Advantage plans have this. Medicare only covers eye care for conditions like cataracts or glaucoma.
❌ 4. Hearing Aids & Exams. Audiology exams may be covered but fitting hearing aids and the hearing aids themselves are not covered. Medicare Advantage has hearing benefits but they are rare the good devices or high-level hearing aids.
❌ 5. Prescription Drugs (Outpatient) Original Medicare doesn’t cover retail prescription meds. You need a stand-alone, Part D plan or a Medicare Advantage plan with drug coverage.
❌ 6. Care Outside the U.S. Medicare usually doesn’t cover medical services while traveling internationally. Some Medigap plans (like Plan G or Plan N) offer limited emergency coverage abroad. The key word is "Emergency". Tracy's tip; Buy a travel plan before leaving the USA
Will I get an Annual Notice of Change (ANOC) every year?
Will you get an annual notice of change every year, or an ANOC? Those who are on a Medicare Advantage Part C plan or a prescription drug plan Part D will receive an annual notice of change annually as the annual enrollment period approaches every October. It's important to review that annual notice of change because it will share with you any changes the insurance company is making to the plan and to coverage.
Now, those who are on original Medicare with a supplemental plan, your supplemental plan will not send you an annual notice of change. The annual notice of change, or ANOC, is only sent to those who are enrolled in Medicare Advantage or a Part D standalone prescription drug plan. I hope that helps. Until next time, be healthy and be well.
I signed up for part A. I'm still on my husband's insurance so I didn't sign up for part B. is there a form I need to fill out stating I'm still on my husbands insurance?
So the question is, I signed up for Part A, I'm still on my husband's insurance so I didn't sign up for Part B. Is there a form I need to fill out stating I'm still on my husband's insurance?
The first thing we need to pick apart is figuring out if your husband's or spouse's insurance is what's known as creditable coverage. Basically what that means is that it's as good as Medicare. Usually the insurance policy from your employer has to have prescription drug coverage, and it has to pay for hospital and medical services. One way to find out if it is deemed creditable is to basically find out from the benefits department of your employer or your spouse's employer.
As far as doing something to prove that you have insurance, you don't need to do that until the time comes for when you need to sign up for Part B. There's a form called a CMS L564 form, which is basically going to show Medicare, the government, that you've had health insurance and will not be hit with a late penalty for Part B.
And then there is a separate form if you have Part A already. That is known as a CMS 40B form, and that is your actual application for the Part B portion. What you do is you upload it on your Social Security portal to apply for Medicare.
But long short of it is that you do not have to prove anything at that time. It just comes down to when you are ready to retire. That's when you get those forms in place to apply.
Is Medicare becoming more expensive over time, and will it ever be unsustainable?
Yes, Medicare's costs are increasing and there are concerns about its long-term sustainability. The aging population and rising healthcare costs are driving up spending, while the Medicare Hospital Insurance (HI) Trust Fund is projected to be depleted in the future.Elaboration:
Rising Costs:
Medicare spending is projected to increase significantly, rising from 3.1% of GDP in 2023 to 5.4% by 2054. This is due to factors like an increasing number of older adults eligible for Medicare and rising healthcare costs.
Population Aging:
The aging population is a major factor in the rise of Medicare costs. As more people reach retirement age, the number of beneficiaries in the program increases, leading to more claims and higher overall spending.
Projected Trust Fund Depletion:
The Medicare Hospital Insurance (HI) Trust Fund is projected to be depleted by 2026. This means that the program may need to rely on other sources of funding or face cuts in benefits to stay solvent.
Other Sustainability Issues:
Beyond the HI Trust Fund, Medicare faces other sustainability challenges, including rising spending in the Supplementary Medical Insurance (SMI) trust fund and concerns about rising premiums and cost-sharing for beneficiaries.
Need for Reform:
To address these challenges, various proposals for Medicare reform have been discussed, including adjustments to payment systems, enrollment options, and benefit packages.
I’ve talked to a few Medicare agents near me already, and everyone seems to push something different. How do I know you’re genuinely looking out for me and not just trying to make a sale?
That’s a very fair question, and I’m glad you asked it. The truth is, most Medicare agents are genuinely trying to do what they believe is best for the person sitting in front of them. Just like in any profession, though, we all develop preferences over time based on our experiences, the clients we’ve served, and the outcomes we’ve seen. That can sometimes come across as “pushing” one option over another, when in reality it’s often shaped by what’s worked well for the majority of their clients.For example, I personally tend to prefer Original Medicare paired with a Medicare Supplement because I value flexibility, predictable out-of-pocket costs, and nationwide access to providers. Over the years, I’ve seen that structure provide peace of mind for many retirees. That said, if someone prefers a Medicare Advantage plan, I don’t dismiss that. In those cases, I usually recommend a specific carrier—not just because of the benefits on paper, but because of the company’s reputation, financial strength, and, most importantly, the satisfaction and service feedback I’ve consistently received from my own clients.
My role isn’t to “sell” you a particular plan—it’s to educate you on how each option works and help you choose the one that fits your doctors, prescriptions, budget, and comfort level with risk. If at the end of our conversation you feel informed and confident in your decision, whether you enroll through me or not, then I’ve done my job. I want long-term relationships built on trust, not one-time transactions.
Can my daughter work with a Medicare agent or broker on my behalf?
Yes, absolutely. In fact, many of the Medicare clients I work with have an adult child helping them through the process.Your daughter can gather information, compare options, attend appointments, ask questions, and help you evaluate plans. The only limitation is that if she is not your legal Power of Attorney (POA), she cannot enroll you in a Medicare plan on your behalf without your participation.
Once we’ve identified the best option, we’ll simply schedule a time when you’re available and complete the enrollment together. That can be done through a three-way phone call, a Zoom meeting, or an in-person appointment. Many families find this approach helpful because it allows everyone to be involved in the decision and ensures that the parent understands and agrees with the coverage being selected.
How do I report a suspicious Medicare billing error without getting in trouble myself?
If you suspect Medicare fraud or abuse without risking personal repercussions, here's how you can report it:1. Consider the Senior Medicare Patrol (SMP):
SMPs are state programs funded by the federal government, providing free assistance to Medicare beneficiaries in detecting and preventing healthcare fraud and abuse.
They have staff and volunteers who can help you understand your Medicare Summary Notice (MSN), identify suspicious activity, gather evidence, and guide you through the reporting process.
You can find your local SMP program by visiting their website or by calling them
2. Contact the appropriate agencies directly:
Medicare: Call 1-800-MEDICARE
Department of Health and Human Services (HHS) Office of the Inspector General (OIG): Call their fraud hotline at ( 1-800-HHS-TIPS) or file a report online. You are not required to identify yourself when reporting.
Medicare Advantage or Part D plans: If the suspected fraud involves a private Medicare Advantage or Part D plan, contact the plan directly.
State Health Insurance Assistance Program (SHIP): Visit shiphelp to find your local SHIP.
3. Important Considerations:
Review your Medicare Summary Notice (MSN): Regularly review your MSN to identify services or supplies that were billed to Medicare.
Consider contacting the provider directly: If you think a charge is incorrect, you may want to call the provider's office to ask for an explanation.
Whistleblower protections: Whistleblower protections exist under the False Claims Act and other federal laws.
Anonymity: You can report Medicare fraud anonymously to agencies like the OIG and CMS.
In summary, you have several options for reporting suspicious Medicare billing errors without getting in trouble yourself. Utilizing resources like the SMP, contacting Medicare directly, or reporting to the HHS-OIG hotline can help ensure your concerns are addressed appropriately.
Should Medicare cover dental, vision, and hearing, or would that just make it more expensive for everyone?
What Medicare Covers NowOriginal Medicare (Parts A & B) does not cover routine dental, vision, or hearing.
It only covers these services if they’re tied to a medical condition (for example, dental surgery after an accident, or an eye exam for diabetes).
Many people add a standalone dental or vision plan or choose a Medicare Advantage plan that bundles these extras in.
The Case for Adding Coverage
Pro: It could make care more affordable for older adults, since things like dentures, glasses, and hearing aids are expensive.
Pro: Preventive dental and vision care may help avoid bigger (and more costly) health problems down the road.
The Trade-Off
Con: If Medicare added dental, vision, and hearing for everyone, premiums would almost certainly rise across the board to cover the extra benefits.
Con: Not everyone uses these services equally, so some people would end up paying for coverage they don’t use.
The Current Balance
Right now, Medicare keeps premiums lower by sticking to hospital and medical coverage. People who want extra dental, vision, or hearing benefits can choose a Medicare Advantage plan with those perks, or buy a separate plan. That way, the cost isn’t spread to everyone.
Should I review my ANOC with my Medicare agent?
The first thing you should do when you receive your Annual Notice of Change is simply review it. It will be a side by side comparison of your current coverage versus the coverage you will have the following year should you decide to remain in the plan. It's the single best way to stay informed about changes in your policy from year to year. If you see anything that concerns or confuses you then reach out to your agent. If you're okay with the changes you see then just do nothing and the policy will be rolled over to the following year automatically.NOTE: If a plan is not renewing, or is exiting your market entirely, the plan does not send a standard ANOC because there are no "changes" to describe for a plan that won't exist next year. Instead, the plan is required to send a separate non-renewal or termination notice to affected enrollees. This notice informs you that the plan is ending, explains what happens next (e.g., whether you'll be automatically enrolled/"mapped" into another plan offered by the same company, or if you'll be disenrolled). If you receive one of these notices you should immediately set up an appointment with your agent during the Annual Enrollment Period (Dates: 10/15–12/7) or a Special Enrollment Period if applicable.
What should people know about Medicare and its parts?
What does Medicare cover and not cover? To answer this question, we need to take a look at the two different parts of Medicare. Medicare has part A, which is your hospital coverage, and part B, which is your medical coverage. Part A, typically, people do not pay a premium for part A unless you did not work for at least 40 quarters within your lifetime. But part A is gonna cover your inpatient hospital care, some skilled nursing care, and hospice care. There is a deductible of $1,676 every time you go in the hospital. And if you're there more than 60 days, there's a co-pay of $419 per day. From date 91 to 150, it goes up to $838 per day. And then after that, you'll be paying for everything as it is not covered. For skilled nursing facility care, Medicare will cover you for the first 20 days, and then after that, $209.50 per day up to day 100. And then after day 100, you're not covered. So everything will be out of pocket. Your part B covers your doctor services, your outpatient services, including surgery and some other services and supplies that are not covered by part A. There is a premium for your part B. Most people will pay $185 per month, but it does go up based on your income. Part B has an annual deductible of $257. And then after that, 20% is what your co-insurance would be. So there are two different types of plans that you can get: Medicare Supplement and Medicare Advantage to cover the things that Medicare does not cover.
If you could change one thing about the Medicare system, what would it be and why?
👉 Add a true annual out-of-pocket maximum to Original Medicare (Parts A & B)Right now:
Medicare Part A and
Medicare Part B
have no cap on how much someone can spend in a year.
That means:
A long hospitalization
Expensive chemotherapy
Repeated outpatient procedures
could result in unlimited 20% coinsurance under Part B.
Why this is the biggest weakness
Nearly every other form of insurance has a maximum out-of-pocket limit:
Medicare Advantage plans are required to have one.
Employer insurance has one.
ACA marketplace plans have one.
But Original Medicare doesn’t — unless you buy a Medigap policy like Medigap Plan G.
That creates two problems:
1️⃣ Financial risk for people who can’t afford Medigap premiums
2️⃣ Inequity, because protection depends on whether you can buy supplemental coverage
What the change would do
If Original Medicare had, for example, a $5,000–$6,000 annual cap:
People without Medigap would have real financial protection
The system would be easier to understand
It would reduce fear of catastrophic medical debt
Fewer people would feel pressured to move to Medicare Advantage purely for the out-of-pocket limit
Why this matters especially for people like you
Since you mentioned having Plan G and Part D earlier, you already understand how complex Medicare layering can be.
The current structure:
Parts A & B
Medigap
Part D
Or Medicare Advantage
is confusing and financially uneven.
A built-in cap in Original Medicare would simplify decisions and protect the most vulnerable beneficiaries.
How do you get paid, and does it affect the plan you recommend?
It is a common and fair question to ask how we are paid and whether that impacts the plans we recommend. To be fully transparent: The cost of your plan is exactly the same whether you sign up through an agent, a broker, or directly with the insurance company. You pay no fees for my services; instead, the insurance carriers pay a commission to our agency for the work we do.For Medicare Advantage and Part D the Centers for Medicare & Medicaid Services (CMS) sets a Maximum Broker Compensation. This creates a level playing field and is designed specifically to prevent "steering" toward a plan just because it pays more commission. Most carriers pay the same flat fee, meaning my compensation is generally the same regardless of which plan you choose. In North Carolina, some plans are "non-commissionable," meaning the carrier pays the agent $0. Our agency has helped many clients enroll in these plans. If a non-commissionable plan is the best fit for your specific health needs and budget, that is exactly where we will point you.
Medigap compensation works differently. These are usually percentage based rather than a flat fee. Agents typically receive a percentage of the annual premium. This percentage is often higher in the first year and then transitions to a lower renewal rate for subsequent years. While percentages vary by carrier.
Our agency does not focus on individual commissions; we focus on volume and long-term relationships. We choose plans based on:
Plan Benefits: Does it cover what you need?
Provider Networks: Are your doctors included?
Customer Service: How does the carrier treat you when you have a claim?
We believe that if we do the right thing and provide excellent service, a strong customer base and referrals will follow. Our priority is and always will be, finding the plan that is right for you, not the one that pays the most.
Eve Black Venters, CSA
Certified Senior Advisor
How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?
Step 1: Review the Denial NoticeYou will receive a denial letter or Notice of Denial of Medical Coverage (for Medicare Advantage) or a Part D Explanation of Benefits. This notice should include:
• The reason for the denial
• Instructions on how to file an appeal
• Deadlines for submitting your appeal
⸻
Step 2: Request a Redetermination (First Level of Appeal)
Original Medicare
• Fill out a “Redetermination Request Form” (optional— you can also write a letter).
• Send it to the address listed in the denial notice.
• You must file within 120 days of the date you received the denial.
• A Medicare Administrative Contractor (MAC) will review your case.
Medicare Advantage (Part C) or Part D Drug Plan
• You (or your doctor) can request a reconsideration.
• Call your plan or submit a written request.
• For urgent cases, request an expedited (fast) appeal if waiting could seriously harm your health.
⸻
Step 3: Add Supporting Documentation
It’s helpful to include:
• A letter from your doctor explaining why the procedure or medication is medically necessary
• Relevant medical records
• Any prior approvals or evidence of similar cases being approved
⸻
Step 4: Follow the Appeals Process Through the 5 Levels (If needed)
If your first appeal is denied, you can continue through these levels:
1. Redetermination/Reconsideration by the plan or Medicare contractor
2. Review by a Qualified Independent Contractor (QIC)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council
5. Federal District Court Review
Each level has deadlines and procedures, and you’ll be notified how to proceed to the next step if necessary.
⸻
Need Help?
• 1-800-MEDICARE — for guidance on appeals
• State Health Insurance Assistance Program (SHIP) — free, local help
• Your doctor or medical provider — can assist with medical justification
• Medicare.gov — has forms and additional details
Sample Medicare Appeal Letter
[Your F
Should I sign my parents up for Medicare?
Here are the key things to consider:1. Are they 65 or older?
• If yes and not enrolled yet: They generally should enroll during their Initial Enrollment Period (IEP) – the 7‑month window starting 3 months before the month they turn 65 and ending 3 months after.
• If already over 65 and not enrolled: This can be more urgent; they may face late enrollment penalties or gaps in coverage if they wait longer.
2. Do they have other coverage now?
• If they’re still working (or covered under a working spouse’s employer plan) and that plan is from a large employer (20+ employees), they may be able to delay some parts of Medicare without penalty.
• If their only coverage is individual insurance, COBRA, retiree coverage, or a small‑employer plan, they usually should enroll in Medicare at 65 to avoid penalties and ensure primary coverage.
3. Which parts of Medicare are we talking about?
• Part A (Hospital): Often premium‑free if they worked enough years; most people should enroll at 65 unless there’s a special case (e.g., they contribute to an HSA and want to keep doing so).
• Part B (Medical): Has a monthly premium; delaying it without qualifying employer coverage can cause lifetime penalties and delayed access to doctors/ outpatient care.
• Part D (Drugs) or a Medicare Advantage plan (Part C) or Medigap may be needed depending on their health and prescriptions.
4. Penalties and costs if you wait too long
• Part B penalty: 10% higher premium for each full 12 months they could’ve had Part B but didn’t, often for life.
• Part D penalty: 1% of the “national base premium” per month they go without creditable drug coverage, also typically for life.
5. How to actually help them sign up
• Create or use their my Social Security account at ssa.gov.
• Enroll in Medicare Part A and B through Social Security (online, phone, or in person).
• Then decide:
• Original Medicare (A & B) + Part D + optional Medigap, or
• Medicare Advantage (Part C) that bundles A, B, often D, and extras.
Is Guaranteed Issue available after the Medicare Open Enrollment period ends?
Absolutely! Guaranteed Issue rights protect you from being denied a Medicare Supplement plan—even after your Open Enrollment period has passed—as long as you meet certain conditions.For instance, when you turn 65, you’re granted a 6-month Guaranteed Issue window to enroll in a Medicare Supplement plan without any medical underwriting. During that time, you cannot be denied coverage.
There are also special circumstances that trigger these rights. Say you originally enrolled in a Medicare Supplement plan, then switched to a Medicare Advantage plan to test it out. If it’s been less than 12 months, you’re eligible to use the Trial Right Special Enrollment Period (SEP) to return to your original Supplement plan with Guaranteed Issue protection. Note: this option is available only once in your lifetime and only within that 12-month period.
Another scenario would be if your Medicare Advantage plan is discontinued in your area. In that case, you’re entitled to a Guaranteed Issue right to enroll in a Medicare Supplement plan without having to go through medical underwriting. However, you must act within 63 days of your Advantage plan ending.
Your best next step? Connect with a knowledgeable local broker who can help you understand your rights and explore your coverage options. They’ll make sure you don’t miss a beat.
Why did I receive a Medicare Summary Notice, and what should I do with it?
A Medicare Summary Notice (MSN) is a statement you receive every 3 months if you have Original Medicare. It’s not a bill—it shows the medical services you received, what Medicare paid, and what you may owe. Review it carefully to make sure the information is correct, compare it with your doctor’s bills, and keep it for your records. If you notice any mistakes or charges for services you didn’t receive, report them to Medicare at 1-800-MEDICARE.
Will private hospitals accept Medicare plans?
Most private (non‑government) hospitals in the U.S. accept Medicare, but it depends on which type of Medicare you have and whether the hospital is in a specific plan’s network.Original Medicare vs Medicare Advantage
With Original Medicare (Part A and Part B), you can use any hospital or provider in the country that “accepts Medicare,” and the vast majority of non‑pediatric hospitals do.
With a Medicare Advantage plan (Part C), the key issue is the plan’s network, not just “Medicare.” A hospital can accept Medicare but still be out‑of‑network for a specific Advantage carrier or HMO/PPO.
“Accepts Medicare” and “accepts assignment”
Hospitals and doctors that “participate in Medicare” agree to bill Medicare and follow its payment rules.
If a hospital “accepts assignment,” it takes the Medicare‑approved amount as full payment for covered services, which gives you the lowest out‑of‑pocket costs.
Some providers are “non‑participating”; they still take Medicare but may charge up to 15% above the Medicare‑approved amount (the limiting charge).
Important exceptions
VA hospitals and active military hospitals generally do not take Medicare; they bill VA or TRICARE instead.
Some boutique or concierge practices fully opt out of Medicare, using private contracts where you pay out‑of‑pocket and Medicare pays nothing.
How to check a specific private hospital
Use Medicare’s Care Compare tool to look up a hospital; it will show whether the facility participates in Medicare.
If you have Medicare Advantage, call the hospital billing office and ask, “Are you in network for [your plan and carrier]?” because network status is what determines coverage.
Why does Medicare allow insurance companies to bombard seniors with confusing mail and TV ads?
Insurance carriers are for-profit companies. Their Medicare Advantage plans make money by spending less on a member's healthcare than the government payments they receive from Medicare. So, the more people they enroll, the more money they make.The Centers for Medicare & Medicaid Services (CMS) has strict restrictions and guidelines on what insurance companies, agencies, and agents/brokers can and cannot advertise.
Unfortunately, many agencies and marketing firms slip in phrases like, "if eligible", and, "qualified members" with their ads. This is especially true when pushing Over the Counter (OTC) cards that can be used to pay for groceries.
I personally have had dozens of calls from seniors asking how they get their $[insert 4-digit number] check? I've had to explain that some ads walk the fine line using phrases that make it seem like people are entitled to big dollar checks, rebates, and even free dental coverage.
Bottom line is the are legal, provided they don't flat out say something that is definitely untrue (which is why they qualify with those phrases like "if eligible" and "qualified members" to enroll as many people as possible.
This is why it's wise to use a licensed health insurance broker who is certified to sell Medicare Advantage plans (like me) instead of going through Medicare.gov or an insurance agency where you talk to an agent in a call center who has quotas to meet.
What's the deal with Medicare covering medical equipment like wheelchairs- do I need a special approval?
Medicare Part B covers durable medical equipment like wheelchairs as long as it’s medically necessary and prescribed, and some items, especially power chairs, require prior authorization before you can get them. Under Original Medicare, you typically pay 20% coinsurance after the Part B deductible unless you have a Medigap plan that covers that amount. Many Medicare Advantage plans work differently and may offer allowances that let members get certain mobility items at places like CVS or through their OTC catalog, though big equipment still requires approval.
With a Medicare Advantage plan after I reach the max out of pocket, $3,000 or more, will I have any copays or fees the rest of the year?
Yes, that's right. Once you reach the out-of-pocket maximum for covered health services (not counting Part D prescription drug costs which are treated separately), your Advantage plan will pay out @ 100% for Medicare-covered and plan-covered health services. Be sure to get prior authorizations from your Advantage plan before taking on anything out of the ordinary such as CT scans, MRI's, surgeries, infusions, certain durable medical equipment and / or hospital stays. "Medically necessary" health services will generally be covered and will count towards your out-of-pocket maximum with a Part C Medicare Advantage plan.
What are the different benefits of Medicare Advantage from Medicare? Is Medicare Advantage more beneficial for someone with several health issues?
Medicare Advantage (Part C) offers some different benefits compared to Original Medicare. It often includes additional services like dental, vision, hearing, and prescription drug coverage, which Original Medicare does not cover unless you buy separate plans. Medicare Advantage plans also have an annual out-of-pocket maximum, which can provide financial protection if you have high medical costs—something Original Medicare lacks. However, Advantage plans typically require you to use a network of doctors and hospitals, meaning fewer doctors accept them compared to Original Medicare, which is accepted by most providers nationwide. This can be a drawback, especially if you see many specialists or need care from providers outside the plan's network. While premiums for Medicare Advantage plans are often lower, you may pay more out of pocket through copays and coinsurance when you actually use services. In contrast, Original Medicare combined with a Medigap plan and Part D drug coverage usually costs more per month but offers broader access to care and more predictable costs. For people with multiple or serious health issues, the choice depends on whether they value flexibility and access (Original Medicare) or lower premiums and extra benefits (Medicare Advantage). It's wise to speak with a licensed, independent insurance agent who can compare multiple plans.
Isn't Medicare headed for a crisis with so many baby boomers aging into the system?
As more baby boomers age into Medicare, the system is under pressure, especially the Hospital Insurance (Part A) trust fund.Experts do project that this part of Medicare could face funding shortfalls in the coming years, possibly as soon as the 2030s. That doesn’t mean Medicare is going away, but it does mean changes may be needed to keep the program strong for future generations.
It is important to note that if you’re already on Medicare or close to enrolling, your benefits are not in immediate danger. The Medical & Drug Insurance (Part B and Part D), which covers doctor visits and prescriptions, is funded differently and isn’t at risk of running out of money in the same way. Lawmakers are consistently exploring solutions.
Bottom line: it is not a crisis, it just might be an adaptation and change in the future years.
How can I avoid or reduce IRMAA charges on my Medicare premiums?
Great question—IRMAA catches a lot of people off guard, especially around retirement.First, quick refresher (in plain English)
IRMAA = Income-Related Monthly Adjustment Amount
It’s an extra charge added to your Medicare Part B and Part D premiums if your income is above certain limits.
Important (and annoying) detail:
Medicare looks at your income from TWO YEARS AGO.
So in 2026, they’re usually using 2024 tax data.
How to avoid or reduce IRMAA (the practical stuff)
1. Watch your “MAGI” like a hawk
IRMAA is based on Modified Adjusted Gross Income (MAGI), not just your paycheck.
Common things that push people over the line:
Large IRA or 401(k) withdrawals
Roth conversions
Capital gains from selling property or investments
One-time bonuses or severance
Required Minimum Distributions (RMDs)
💡 Strategy: Spread income over multiple years when possible instead of taking a big hit in one year.
2. Use Roth accounts strategically
Roth IRA withdrawals do not count toward MAGI
Partial Roth conversions done before age 65 can reduce future IRMAA exposure
This is one of the most powerful long-term planning tools.
3. Time big financial moves carefully
If you can control when income hits:
Delay selling investments until a lower-income year
Spread withdrawals across December/January to straddle tax years
Avoid stacking multiple income events in the same year
Sometimes staying $1 over the limit can cost thousands in extra premiums.
4. File an IRMAA appeal if your income dropped
This is HUGE—and underused.
If your income went down due to a life-changing event, you can ask Social Security to reduce or remove IRMAA.
Qualifying events include:
Retirement or work reduction
Loss of income-producing property
Divorce or death of a spouse
Employer settlement ending
You do this using SSA Form 44.
👉 This can lower your premiums immediately, not years later.
5. Coordinate Medicare decisions with tax planning
This is where people get burned:
Medicare choices
Should I worry about my income effecting my Medicare eligibility?
No, income does not affect your eligibility for Medicare, however, if your income is above a certain threshold, an IRMAA (Income Related Monthly Adjustment Amount) will be applied to your Part B & Part D monthly premiums. The IRMAA is determined by your tax returns from 2 years ago- 2026 will be determined by your 2024 tax returns. There is an appeal form on the Social Security website ssa.gov. I recommend checking to see if an appeal category applies to your situation.
Should I worry about Medicare cuts?
Due to recent congressional actions, Medicare cuts are a valid and serious concern particularly for those with low incomes, individuals in Medicare Advantage plans, and certain healthcare providers. Reduced benefits and fewer plan choices: Many MA plans have responded to funding cuts by reducing extra benefits, such as vision and dental, and by increasing cost-sharing and deductibles. Some insurers are trimming or exiting unprofitable markets. Steps you can take: Stay informed during Open Enrollment (October 15 to December7) to understand changes to your specific plan for the upcoming year. Review your plan. Compare all available options in your area. Explore financial assistance: If you have limited income, re-examine your eligibility for Medicare Savings Programs and Part D subsidies.
What states have the Medigap "birthday rule" and what is it?
A Medigap “birthday rule” provides current Medigap enrollees with a short, guaranteed-issue window each year around their birthday to switch plans without undergoing medical underwriting (usually to the same or lesser benefits; exact rules vary by state).States with birthday rules (as of Sept 2025):
CA: 60 days from the first day of your birth month; equal or lesser benefits; can change carriers.
California Department of Insurance
OR: 30 days from the first day of your birth month; equal or less; can change carriers.
Oregon SHIBA
ID: 63 days after your birthday; equal or less; can change carriers.
Idaho Department of Insurance
IL: 45 days after your birthday (ages 65–75); equal or less; same carrier or affiliate.
MD: 30 days after your birthday; equal or less benefits.
NV: 60 days from the first day of your birth month; equal or less; can change carriers.
Nevada Division of Insurance
LA: 63 days after your birthday; equal or lesser; generally same carrier/affiliates.
OK: 60 days after your birthday; similar/equal or lesser; can change companies.
Oklahoma Insurance Dept.
KY: 60 days after your birthday; same benefits; can change carriers.
UT (effective May 7, 2025): 60 days after your birthday; equal or lesser; same insurer only.
Utah Legislature
+1
VA (effective July 1, 2025): 60 days after your birthday; same letter plan with any insurer.
Virginia SCC
WY (effective June 4, 2025): 63 days after your birthday; equal or less; can change plan/carrier.
Wyoming DOI
IN (effective Jan 1, 2026): 60 days after your birthday; same letter plan with any insurer.
LegiScan
+1
Related protections: Missouri has an anniversary rule (60-day window around your policy anniversary to switch to a same-letter plan, often with a new carrier); Washington lets you switch anytime to equal/lesser benefits with the same insurer; CT & NY have year-round Medigap guarantee
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.
How do Medicare Savings Programs help with Medicare costs?
Medicare Savings Programs (MSPs) are essentially a "financial bridge" provided by your state to help cover some of the costs that Medicare doesn't.Depending on your income and savings, these programs help in three main ways:
Paying your Part B Premium: For most people in 2026, this saves you about $202.90 every single month. Instead of this being deducted from your Social Security check, the state pays it for you.
Lowering Out-of-Pocket Costs: The most helpful level (called QMB) acts like a secondary insurance, covering your Medicare deductibles, coinsurance, and copayments so you don't get hit with big bills after a doctor's visit.
Automatic Prescription Savings: If you get into an MSP, you automatically get "Extra Help." This is a federal program that lowers your prescription drug costs, usually capping your copays at a few dollars.
A Medicare supplement broker told me something about "extra lifetime reserve hospital days". What are those and how do they work?
Lifetime reserve days are a one-time backup supply of 60 additional hospital days that Original Medicare gives you to use after you've exhausted your standard inpatient benefit in a single benefit period.How the standard benefit works first. Medicare covers inpatient hospital stays in "benefit periods." Within each benefit period, you get up to 90 days of covered hospital care. Days 1–60 have no daily coinsurance (just the Part A deductible), and days 61–90 come with a daily coinsurance charge ($816/day in 2026). Once you've used those 90 days in a single benefit period, you've hit the wall — that's where lifetime reserve days kick in.
What lifetime reserve days are. The extra 60 days are a pool that sits on top of your standard 90-day benefit. They are not renewable — you get exactly 60 of them across your entire lifetime, to be used however and whenever you need them. In 2026, each lifetime reserve day comes with a $1,632 daily coinsurance (double the days 61–90 rate), which you pay out of pocket.
How they're used. They kick in automatically on day 91 of a continuous hospital stay within a single benefit period, unless you explicitly opt out in writing. Once used, those days are gone permanently — even if you later switch Medicare plans or take a break in coverage.
You can decline to use them. If you'd rather preserve your lifetime reserve days — say, because you have a Medigap policy that would cover the gap differently, or you want to save them for a potentially longer future stay — you can submit a written request to the hospital to not use them. The hospital is then required to issue you a denial notice, which you can use to appeal or to trigger other coverage.
Why they matter less with Medigap. Most Medigap supplement plans (Plans A, B, C, D, F, G, etc.) cover the lifetime reserve day coinsurance, and some cover an additional 365 hospital days beyond Medicare's limits entirely. So if you have a supplement, the $1,632/day charge may be fully covered anyway.
M
Why does Medicare have so many coverage gaps, and is it designed that way on purpose?
That’s a thoughtful question, and the short answer is: yes, Medicare’s gaps are largely by design.When Medicare was created in 1965, it was never intended to cover everything. The structure was built to:
• Share costs between you and the program (deductibles, 20% coinsurance) to help control overall spending
• Focus on medical care, not things like dental, vision, or hearing, which were considered outside core coverage at the time
• Leave room for private insurance—that’s why Supplement (Medigap) and later Medicare Advantage plans exist to fill in those gaps
Over time, healthcare has evolved, but the basic framework hasn’t fully kept up—so those gaps are still there today.
Bottom line:
Medicare gives you a strong foundation, but it was intentionally designed to be paired with additional coverage if you want more complete protection.
Are Medicare agents paid by specific insurance to sign up clients to their plans only
Many insurance companies offer a commission when enrolling a client in a plan. Independent brokers often represent multiple carriers, thus they are not typically incentivized to sign up a client with one carrier over another carrier as most commission structures are the same. This is not too dissimilar to a home or automobile insurance broker. Those brokers also typically shop rates across multiple carriers and therefore are incentivized to find the best coverage for the client at the lowest possible rate. The same holds true for most independent Medicare agents. If the agent is a captive agent, however, then they only work for one carrier, and they are therefore incentivized to only sell plans for that one carrier. I would beware of any agents calling clients from a call center or directly from the health plan as these are all typically captive agents and again incentivized to only write plans for that one particular carrier. They are driven by sales metrics and not what’s in the best interest of the client.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.
Do I have to pay taxes on Medicare?
No, you don’t pay taxes on your Medicare benefits. Medicare isn’t counted as taxable income. What you will pay are your monthly premiums and any copays or deductibles when you use your coverage.If your income is on the higher side, Social Security may add something called an IRMAA to your Part B or Part D premiums. It’s not a tax, but it does mean you’ll pay more than the standard premium.
So the short answer is: your Medicare itself isn’t taxed, but you’ll still have your regular premiums and costs to keep in mind.
I am moving to a new state in a few months. What's a good Medicare check list to make sure I am not missing anything in my new state?
Moving to another state can affect your Medicare coverage more than many people realize. Here’s a Medicare Relocation Checklist to keep you organized:-Notify Social Security and Medicare: Call Social Security (1-800-772-1213) or log in at ssa.gov/myaccount to update your address and mailing info.
This ensures you keep receiving important Medicare correspondence and premium notices (especially if you pay your Part B directly).
- Original Medicare (Parts A & B): Your Original Medicare coverage travels with you anywhere in the U.S. You can continue to use any provider who accepts Medicare nationwide. Just confirm your new doctors accept Medicare assignment to avoid surprise bills.
- Prescription Drug Plan (Part D): Part D plans are state-specific, so when you move you’ll likely need to select a new plan available in your new ZIP code. You’ll qualify for a Special Enrollment Period (SEP) to switch plans. Compare plans at Medicare.gov/plan-compare or contact an agent to receive help.
- Medicare Advantage (Part C): MA plans are tied to service areas; moving out of state almost always requires a plan change. You’ll have a 2-month SEP starting from your move date to join a new plan in your new state.
-Dental, Vision, and Other Add-Ons: If your current MA plan includes extra benefits (dental, vision, OTC, transportation, etc.), check whether equivalent options exist in your new state — many carriers differ by region.
-Supplemental (Medigap) Policy: Medigap policies are state-regulated. Some states require new underwriting when you move; others have guaranteed issue protections.
-Medicaid or Extra Help (if applicable): If you receive Medicaid or LIS/Extra Help, you’ll need to reapply in your new state, since eligibility rules vary.
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.
Can you explain how Medicare works with other types of insurance like Veterans Affairs benefits or employer plans?
Medicare can work alongside other insurance, but who pays first (primary) and who pays second (secondary) depends on which type of coverage you have and why you have it.1. Employer or Union Group Health Plans
If you’re 65+ and still working (or covered by a working spouse’s plan):
Employer has 20+ employees: Employer plan pays first, Medicare pays second.
Employer has fewer than 20 employees: Medicare pays first, employer plan pays second.
Tip: Always confirm with HR whether your coverage is considered creditable for delaying Part B or Part D without penalty.
2. Retiree Coverage
Usually pays after Medicare.
You must enroll in Medicare Parts A & B for retiree coverage to work fully.
Retiree coverage may help pay Medicare’s deductibles and coinsurance, but benefits can change — especially if your former employer changes the plan.
3. Veterans Affairs (VA) Benefits
VA benefits cover care only in VA facilities.
Medicare covers care in non-VA facilities.
You can have both:
Use VA for prescriptions or specialty care.
Use Medicare for civilian doctors/hospitals.
Tip: Many vets keep Part B to avoid penalties and to have access to non-VA care.
4. TRICARE for Life (Military Retirees & Spouses)
You must have Medicare Parts A & B.
Medicare pays first for Medicare-covered services.
TRICARE pays second, often covering what Medicare doesn’t (including some drugs).
For VA or military facilities, TRICARE pays first.
5. Medicaid
Medicaid is always the payer of last resort — it pays after Medicare and any other insurance.
If you have both Medicare and Medicaid (“dual eligible”), you may qualify for a Special Needs Plan (D-SNP) that coordinates both.
6. Workers’ Compensation
Workers’ comp pays first for job-related injuries or illness.
Medicare may pay for unrelated services.
Is it better to update your Medicare plan often, or to get a plan that will work long term?
The answer to this question lies in the middle. It depends on the types of plan you have and your personal situation. If you have a Medicare Supplement, your coverage doesn't change so changing for that reason isn't necessary. If your premium has become cost prohibitive, you can look for a less expensive supplement, but remember you will need to pass underwriting if you are outside of your guaranteed issue period.If you are on a Medicare Advantage plan then you may want to check your plan annually, but not necessarily change it. When the MAPDs come out in the Fall, you are sent a letter that explains how your plan will change. If there is something significant that is changing, then you may want to shop around to see if another plan can be a better fit. If there isn't much change, I don't suggest moving. If your plan has worked fine for you and your providers, then stay with it.
In general having a plan for the long run creates fewer issues when it comes to getting care. However it doesn't hurt to look at the new MAPDs each year as they can change significantly and you don't want to be surprised later in the year.
Are there any changes I should expect for Medicare in 2026?
Absolutely! Like past years, the Part A deductible and copays will increase. The Part B Premium and annual deductible will also be increasing.In addition to those increases, Part D premiums will be increasing dramatically for many people. Along with higher premiums, people will see higher drug costs, stricter formularies and fewer plans available.
Advantage plans are also changing. Many plans are being eliminated completely. Plans that are remaining are seeing an increase in copays and a decrease in many of the extra benefits. Be sure to read your ANOC letter to see how your plan is changing.
For Medicare supplement owners, in addition to the part D increases, monthly premiums will continue to rise. Although, these increases are specific to each carrier.
Overall 2026 looks to be a tumultuous year for Medicare beneficiaries, agents, providers and carriers.
Won't Medicare run out of money before I can benefit from it?
Medicare isn’t expected to “disappear,” even though you may hear it’s “running out of money.”- The warning you hear is mainly about Medicare Part A (hospital insurance). The Part A Trust Fund is projected to face a shortfall in the mid‑2030s. If Congress did nothing, Part A could still pay a large share of benefits—just not 100%—so it would mean reduced payments, not Medicare ending.
- Medicare Part B (doctor/outpatient) and Part D (prescriptions) don’t work the same way. They’re funded largely by monthly premiums and general tax revenue, so they aren’t set up to “run out” in the same way.
- Historically, Congress has stepped in when deadlines approach (through tax changes, payment changes, etc.). The fixes can change costs or rules, but beneficiaries typically continue to have coverage.
Bottom line: People on Medicare today still use it every day, and it’s very likely to be there for you. It’s usually a good idea to choose coverage based on your health needs and budget now, rather than trying to time political headlines.
Can a Medicare broker help us find a plan that includes broader chiropractic coverage?
Absolutely — that’s one of the best reasons to work with a Medicare broker. Here’s the clear breakdown:What Original Medicare Covers
Chiropractic: Only manual adjustment of the spine if it’s medically necessary to correct a subluxation.
Nothing else — no exams, no X-rays, no maintenance, no wellness visits.
Where Brokers Can Help
Medicare Advantage plans (Part C): Many carriers add extra chiropractic visits, sometimes unlimited, sometimes capped (e.g., 12–24 visits per year).
Some plans also package chiropractic with acupuncture, massage therapy, or physical therapy as part of a broader wellness benefit.
Brokers can compare side-by-side what each plan in your county offers.
Why It Matters
Coverage for chiropractic beyond the narrow Medicare standard varies wildly by carrier and county.
A broker has access to all those plan details and can pinpoint which ones give you broader chiropractic coverage (without you having to read 200 pages of Evidence of Coverage).
Am I responsible for an IRMAA surcharge?
2025 Medicare beneficiaries with higher incomes will pay surcharges, known as IRMAA (Income-Related Monthly Adjustment Amount), on top of their standard Part B and Part D premiums. These surcharges are based on modified adjusted gross income (MAGI) from 2023. For 2025, individuals with incomes above $106,000 and couples filing jointly with incomes above $212,000 will be subject to IRMAA. Basically, these surcharge amounts vary based on income brackets, with higher incomes incurring larger surcharges. So if your income falls in these categories, you may get to pay a surcharge.
I am a member of a federally recognized tribe here in Arizona. I receive all my medical needs through the Indian Health Service at no cost. Do I still have to have Medicare?
This is a common question, and the short answer is that while you are not required to have Medicare, enrolling in it is highly recommended and offers significant benefits that support both your health and the Indian Health Service (IHS) system.Here is a breakdown of why Medicare is beneficial when you already receive free care through the IHS:
1. Expanded Access to Care
IHS is not insurance: The IHS is a healthcare provider system funded by Congress, not an insurance program like Medicare. This means its services may be limited by budget.
Services outside of IHS: Medicare, especially Part B, gives you access to medical care outside of IHS facilities, such as:
Seeing specialists (since IHS may be limited to primary care).
Non-IHS hospitals or clinics if you are traveling or do not live near an IHS facility.
Services your local IHS facility may not be able to provide.
2. Financial Benefit to the IHS
When you have Medicare and receive a covered service at your IHS or Tribal clinic, the facility can bill Medicare for that service.
This reimbursement saves money for the IHS, increasing the overall resources available to provide more services for the entire community. Since federal funding covers only an estimated 60% of care needed, Medicare payments are a vital revenue source for the IHS.
3. Avoiding Penalties (Specifically Part B)
You are not penalized for delaying Part D (prescription drug) coverage if you have drug coverage through IHS.
However, if you do not sign up for Medicare Part B (medical insurance) when you are first eligible and later decide you need it, you could face a late enrollment penalty that is added to your premium for as long as you have Part B. There is typically no Special Enrollment Period exemption for having IHS coverage for Part B.
Part A (Hospital Insurance) is generally premium-free if you or your spouse worked and paid Medicare taxes for at least 10 years. You should sign up for premium-free Part A when you are eligible.
Speci
How do I budget for Medicare costs if I expect my health to decline in the next decade?
As health declines, you may require more frequent medical visits, higher prescription drug costs, and possibly long-term care.Make sure to:
• Review Medicare coverage: Ensure you understand what parts of Medicare will cover your anticipated needs.
• Consider supplemental insurance: Evaluate Medigap policies or Medicare Advantage plans offering additional coverage.
• Explore Medicaid eligibility: If you have limited income and assets, you might qualify for Medicaid, which can help cover costs not covered by Medicare.
Creating Your Budget:
• Calculate monthly premiums: Include premiums for Medicare Part B, Part D, and any supplemental insurance.
• Account for out-of-pocket costs: Factor in copayments, deductibles, and coinsurance for medical services and medications.
• Prepare for unexpected expenses: Set aside funds for emergencies or unplanned health interventions.
Long-Term Care Planning:
• Investigate long-term care insurance: Consider policies that cover nursing home care, assisted living, or home healthcare.
• Plan for home modifications: Budget for adjustments to your living environment to accommodate changing physical needs.
Additional Resources and Support:
• Financial advisors: Professionals can help create a personalized budget and explore investment options for covering healthcare costs.
• Licensed Agents Offering Medicare Plans: Licensed Agents can review your current plans and compare them with other plans in your area to ensure you have a plan that suits your needs.
• Medicare counselors: State Health Insurance Assistance Programs (SHIP) offer free counseling for Medicare beneficiaries.
Monitoring and Adjusting Your Budget:
• Review your budget: Assess expenses and adjust your financial plan based on changing health and economic conditions.
• Update your insurance coverage: Ensure your plan continues to meet your needs as they evolve.
Would expanding Medicare to younger Americans improve or hurt the program?
It's a great question—and one that gets a lot of attention. It could have both positive and negative effects, depending on how it's done. On one hand, bringing in younger, generally healthier individuals could help stabilize long-term finances by balancing out costs. It could also improve access to care for people who currently struggle with high insurance premiums or go without coverage.On the other hand, Medicare is already facing funding challenges. Adding millions of people without a clear plan to pay for it could strain the system. It could also impact provider access or current beneficiaries if payments to DRS and hospitals are stretched too thin.
Any major change would need to be carefully planned and funded to ensure it strengthens, not weakens, the program.
My role is to help individuals navigate the system as it exists today and prepare for changes if and when they happen.
How much do agents charge to help clients to enroll
Greetings!Agents typically do not charge you a fee to help enroll in Medicare. Licensed Medicare agents and brokers are paid by the insurance company if you enroll in a plan, and their commission is regulated and built into the plan’s premium. That means you pay the same premium whether you use an agent or enroll directly with the insurance carrier. There is no additional cost for their assistance. An agent can help you compare plan options, review provider networks, check prescription drug coverage, and complete enrollment paperwork to ensure your coverage starts on time and fits your needs.
Shouldn't Medicare do more to address health disparities among minority seniors?
Yes, there is a strong argument that Medicare should do more to address health disparities among minority seniors. Research suggests that expanding Medicare, particularly for those under 65, could significantly reduce these disparities. Additionally, Medicare's significant influence as a major purchaser & regulator of healthcare provides opportunities for systemic change to improve access & quality of care for minority beneficiaries.Why Addressing Disparities is Important:
Unequal Outcomes: Minority seniors often experience higher rates of chronic diseases, poorer health status, & lower rates of preventative care compared to their white counterparts.
Structural Factors: These disparities are often linked to social determinants of health like poverty, discrimination, & limited access to quality healthcare, education, & resources.
Financial Strain: Many minority seniors are more likely to rely on Medicaid or less adequate supplemental coverage, putting a greater financial strain on their health care.
Increased Costs: Health disparities lead to higher overall healthcare costs, including those associated with emergency room visits & chronic disease management.
How Medicare Can Help:
Expanded Coverage: Lowering the eligibility age for Medicare could significantly expand access to healthcare for minority seniors, particularly in areas with high rates of disparity.
Targeted Programs: Medicare can create specific programs and initiatives to address the unique needs of minority seniors, such as:
Language access: Ensuring healthcare providers have the ability to communicate effectively with beneficiaries who speak languages other than English.
Cultural competency training: Educating healthcare professionals on the specific cultural & social factors that may affect health outcomes for minority seniors.
Transportation & childcare: Providing assistance with transportation to appointments & childcare services, which can be significant barriers to care.
Why did my Medicare deductible reset in January?
In January, most Medicare deductibles reset because they are based on the calendar year. This annual cycle applies to most health insurance plans, and for 2026, the reset also includes new, slightly higher deductible amounts set by the federal government.How the reset affects you depends on which part of Medicare you are using:
Medicare Part B (Medical Insurance)
Annual Reset: The Part B deductible is strictly an annual requirement that restarts every January 1st.
2026 Cost: For 2026, the annual Part B deductible is $283.
How it Works: You must pay this amount out-of-pocket for doctor visits and outpatient services before Medicare begins to pay its share (typically 80%) for the rest of the year.
Medicare Part A (Hospital Insurance)
Benefit Period Reset: Unlike Part B, the Part A deductible does not reset just because it is January.
Trigger: It resets based on a "benefit period," which begins the day you are admitted to a hospital and ends only after you have been out of the facility for 60 days in a row.
2026 Cost: The 2026 Part A deductible is $1,736 per benefit period. You could potentially pay this multiple times in a single year if you have several hospital stays separated by more than 60 days.
Medicare Advantage & Part D
Part D (Prescription Drugs): These deductibles also reset on January 1st. For 2026, the maximum possible drug plan deductible is $615.
Medicare Advantage (Part C): Most of these plans also follow the calendar year for their deductibles and out-of-pocket maximums. Because these are private plans, your specific deductible amount can change each year on January 1st.
Who will make medical decisions as to what is necessary to me: my Doctor or the insurance company?
Short answer: both.And that's where it gets frustrating.
Your doctor decides what care is medically appropriate for you. They examine you, know your history, and recommend treatment based on what they believe will help. Your insurance company decides what care they'll pay for. They look at your plan's rules, their coverage guidelines, and whether the service meets their definition of "medically necessary."
Those two answers don't always match. Your doctor can recommend an MRI, a specialist, or a procedure, but if the insurance company decides it doesn't meet their criteria, they can deny the claim or require you to try something cheaper first. That's called prior authorization or step therapy, and it's more common than most people realize.
Here's the part folks miss, a denial isn't the final word. You have the right to appeal, and your doctor can submit documentation to fight for the care they recommended. Plenty of denials get overturned when someone pushes back.
So who's really in charge? Your doctor decides what you need. Your insurance decides what they'll pay for. Your job , and ours, as your broker, is to make sure those two line up as often as possible, and to fight when they don't.
What's the difference in copays vs deductibles?
A copay is what you are going to be responsible when you utilize a medical procedure or even when you pick up your medications immediately. A deductible on the other hand is what you will pay first before the insurance company will pay. So, if you are on a plan that has a $300 deductible for medications (for all tiers) then you would pay the first $300 towards any of your medications before the plan would pick up any of the cost. Once the deductible is met then typically there is a set copayment or coinsurance that you are responsible after that point. A deductible is not to be confused with a maximum out of pocket (believe me it commonly is). The maximum out of pocket is the maximum amount you can pay within a year. Once your maximum is hit then the insurance company is to pay the copayments and coinsurance until the end of the calendar year. This resets at the end of each year.Don't you think Medicare's focus on treatment rather than prevention is backwards?
In my opinion, I believe Medicare does focus on prevention, and my reasons are these:1. Medicare's preventative annual physicals are extremely comprehensive, and are covered at $0 copay to the beneficiary. They cover over 35 health screenings for every part of the body, cancer screenings, mental health screenings, tobacco cessation, and many more.
2. Routine colonoscopies, mammograms & PSA screenings are also covered at $0 copay.
3. Vaccinations as recommended by the Advisory Committee on Immunization Practices (ACIP) are covered by Part D at $0 copay. These include the flu shot, pneumonia, COVID, tetanus and other routine immunizations. About 3 years ago, the instructions even encompassed the shingles vaccine at $0, which I believe to be extremely proactive in preventative health measures.
4. Primary Care Physicians and practices are subject to rigorous CMS standards that require alignment with strict protocols in preventative health.
Don't you think Medicare's technology systems are outdated and inefficient?
Yes, many of Medicare’s technology systems are outdated, making processes like enrollment, claims, and provider coordination unnecessarily complex. Modernizing these systems could greatly improve efficiency, user experience, and accessibility for beneficiaries and providers alike.What's a Medicare rule or regulation that's outdated or unfair to seniors?
The "3-Day Inpatient Stay" rule is frequently cited by healthcare experts and advocacy groups as one of the most outdated and unfair regulations in Medicare. It’s a perfect example of a policy created for a different era of medicine that hasn't caught up to modern hospital practices. The 3-Day Rule and "Observation Status" Under traditional Medicare, you are only eligible for covered Skilled Nursing Facility (SNF) care if you have a prior "qualifying" hospital stay of at least three consecutive days as a formally admitted inpatient. The problem is the rise of Observation Status. Hospitals often keep seniors in a bed for several nights for "observation" rather than formally admitting them as inpatients. The Trap: Even if you stay in the hospital for three or four nights, if you are under observation status, those days do not count toward the 3-day requirement. The Unfair Outcome: When you are discharged to a rehab center or nursing home for recovery (like after a fall or surgery), Medicare may refuse to pay. This leaves seniors facing bills that can easily exceed $10,000 or $20,000 for necessary medical recovery because of a technical administrative label. Other "Unfair" Rules Often Discussed: Lifetime Late Enrollment Penalties: If a senior misses their Initial Enrollment Period for Part B or Part D and doesn’t have "creditable" coverage, they face a penalty. Unlike most late fees, this is permanent. They will pay a higher premium every single month for the rest of their lives. The "Big Three" Coverage Gaps: Original Medicare (Parts A and B) still lacks routine coverage for dental, vision, and hearing. Since these three areas are critical for preventing falls, dementia, and social isolation, many argue it is outdated to treat them as "supplemental" rather than essential health care. The Homebound Requirement: To receive Medicare-covered Home Health Care, a senior must be "homebound," meaning it is extremely difficult to leave the house.
What are Special Needs Plans (SNPs) in Medicare Advantage?
There are two types of Special Needs Plans (commonly referred to as SNP) specific to Medicare Advantage plans.1.) C-SNPs are plans that are created to help those seniors who have a CHRONIC health condition, hence the "C" SNP. Chronic health conditions can be diabetes, congestive heart failure, and/or cardiovascular disease. Some carriers go beyond these three chronic conditions, so be sure to discuss health conditions with your independent Medicare agent.
2.) D-SNP's are plans that are created to help those seniors who are "DUAL" eligible. A Dual eligible individual is someone who qualifies for both Medicare and MEDICAID, hence the "D" SNP. There are also various levels of DSNP plans, so be sure to discuss this with our independent Medicare agent so you understand what level you may qualify for.
What is the best MAPD plan in South Carolina?
There is no single “best” MAPD plan in South Carolina — it depends on your county, doctors, prescriptions, and budget. Carriers like Aetna, Devoted Health, Wellcare, and BlueCross BlueShield of South Carolina often offer competitive 4-star or higher plans in many areas. The strongest plans typically balance low premiums, reasonable MOOP limits, solid Part D formularies, and broad provider networks. Star ratings, PPO vs. HMO structure, and local hospital participation should heavily influence the decision. The best plan is the one that aligns with your specific providers and medication profile.What is one Medicare trend that you believe is having a positive impact on Medicare affordability? How is it making a difference?
One positive trend improving Medicare affordability is the Medicare prescription drug cost reforms under the Inflation Reduction Act.Starting in 2025, there is a $2,000 annual cap on out-of-pocket prescription drug costs for Part D plans — a first in Medicare’s history. This change will make medications far more affordable for seniors who currently spend thousands per year on prescriptions.
In addition, insulin costs are capped at $35 per month, and recommended vaccines (like shingles) are now free under Part D. These reforms are already helping beneficiaries better manage costs and stay consistent with their care — improving both financial stability and health outcomes.
How will advancements in wearable health tech (like smartwatches) integrate with Medicare?
Smartwatches are classified as consumer electronics/fitness trackers by Medicare — not medically necessary durable medical equipment — so Original Medicare generally doesn’t cover them.What’s coming:
CMS just launched the ACCESS Model — a 10-year pilot starting July 2026 that will pay health tech companies for wearables, apps, and telehealth tools that improve outcomes for Medicare patients with high blood pressure, diabetes, chronic pain, and depression. This is a major shift — wearables have historically been ineligible for Medicare reimbursement.
The payment model is performance-based:
Tech providers receive partial payment upfront, with full payment only if patients’ health actually improves.
Medicare Advantage is ahead of Original Medicare here:
Some MA plans already offer devices like Fitbit as wellness or supplemental benefits — though those offerings have decreased across many plans for 2026.
Data privacy is an emerging concern:
Proposed legislation like the Smartwatch Data Act would require consumer consent before wearable health data can be sold or shared — but neither it nor similar bills have advanced yet.
What's a common Medicare myth that even some agents still believe?
Plan G is the best plan money can buy:Agents often consider Plan G to be the best Medicare supplement for seniors, but agents don’t consider that Plan N typically offers better long-term value. Since January 1, 2020, Plan G has been the primary "Guaranteed Issue" plan. This means individuals with chronic health conditions can enroll without medical underwriting. These high-cost claims have caused Plan G premiums to skyrocket. In contrast, Plan N requires stricter medical underwriting in most situations, keeping its risk pool healthier. As a result, Plan N clients experience much lower, more stable rate increases. Coverage comparison between both plans is nearly identical with only three minor differences on Plan N: Doctor Copays: $0 Up to $20 per visit, Emergency Room: A $50 copay (waived if admitted), and Excess Charges: You pay the 15% difference if a doctor charges above the Medicare-approved amount, though this is rare and in my fifteen years I have not encountered it yet.
What 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.
What demographic challenges will Medicare face in the coming years?
Here are some demographic challenges that Medicare will face in the coming years.1. Large influx of Baby Boomers still entering Medicare. Baby Boomers will live on average 4.2 years longer than previous generations after turning 65. This demographic shift will put pressure on not only Medicare to fund and cover their care, it will also put pressure on providers being able to meet the demand to care for a large, aging population.
2. Retirees moving from one state to another could also pose a demographic challenge for Medicare. An estimated 10-20% of retirees eventually move to another state…and most of them move to the Southeast (Florida, Georgia, South Carolina, North Carolina, and Tennessee). These states will have to deal with an influx of an aging population that will need healthcare and long-term care services. Therefore, Medicare may have to up the ante for these states and provide more funding to cover the care of Medicare beneficiaries.
3. More and more people have chronic conditions. The number of people with chronic conditions continues to increase with no stopping in sight. Get this…85% of those 65+ have at least one chronic condition, and around 60% have two or more. If the government and the citizens of the US were more proactive in taking care of their health, then this country could save not just billions of dollars, but trillions of dollars. Realize, almost all chronic conditions are avoidable and most of them are curable. And despite the flack some people give about RFK Jr. and Dr. Oz…at least they might try to do something about the epidemic of poor health in this country. There really is no excuse for it. Certainly no other administration, regardless of political party has done much to truly improve the overall healthcare of the citizens and the overall healthcare system.
Those I would say might be the top three demographic challenges Medicare will face in the coming years.
Does Medicare pay for medical alert systems?
Generally, Original Medicare (Parts A & B) does not cover personal medical alert systems (like Life Alert or wearable emergency buttons). They’re considered non-medical, convenience devices rather than medically necessary equipment.Exceptions / alternatives
Medicare Advantage plans (Part C)
Some MA plans offer wellness or home safety benefits, including medical alert systems or subsidized emergency devices.
Availability and amount vary by plan and location.
Home health coverage
If a doctor orders a medically necessary device as part of a home health plan (e.g., certain monitoring equipment), Medicare Part A/B may cover it.
This usually applies to devices that monitor vital signs or connect to a nurse, not standalone alert buttons.
Community programs / grants
Some local aging agencies, charities, or veterans programs provide free or discounted alert systems for seniors at risk of falls or medical emergencies.
Bottom line:
💡 Original Medicare won’t pay for a typical medical alert system, but some Medicare Advantage plans or community programs may help cover or subsidize them.
Is Medicare fraud an issue I should be worried about?
Yes, it’s definitely something to be aware of. Medicare fraud is a real problem, costing Americans a lot of money each year.Scammers know that Medicare is a huge opportunity to take advantage of vulnerable people, so be cautious. The government estimates that Medicare loses tens of billions of dollars each year to fraud, error, and abuse. In 2022 alone, the Department of Justice reported recovering over $1.7 billion in healthcare fraud cases. Seniors are often the main targets because scammers know you rely on your benefits.
What does that fraud look like? Sometimes it involves billing for care you never received. Other times, it’s charging for expensive equipment, like a power wheelchair, when you only received a cane. In some cases, it’s straight-up identity theft—using your Medicare number to file fake claims.
The good news is that most fraud can be caught early if you pay attention. Always check your Medicare Summary Notice or Explanation of Benefits. If you see a doctor visit, test, or piece of equipment you didn’t get, that’s a red flag. And remember—Medicare will never call out of the blue asking for your number or show up at your door.
So yes, it’s worth watching for. But if you treat it like checking your credit card bill—just a quick review—you’ll be ahead of most scammers.
What's a common trick in Medicare marketing that hides restrictions on doctor choices?
A very good question — and an important one, because the way Medicare Advantage (Part C) plans are advertised can sometimes be a little misleading if you don’t read the fine print.One of the most common tricks in Medicare marketing that hides restrictions on doctors is the way plans emphasize “low cost” or “$0 premium” while downplaying network limitations. Here’s how it usually works:
1. Emphasizing Cost, Not Network
Ads often highlight: “$0 monthly premium, dental, vision, hearing, gym membership included!”
What’s not said upfront: those benefits only apply if you use in-network doctors and facilities. Out-of-network care may be limited or not covered at all, except in emergencies.
2. Using Broad Phrases Like “Access to Doctors Nationwide”
Some marketing materials suggest you’ll have access to a “nationwide network.”
In reality, many plans are local HMOs (Health Maintenance Organizations) where you must pick a primary care doctor within a local network and get referrals to see specialists.
3. Hiding Prior Authorization Requirements
Plans may promote coverage for expensive services (like MRIs or skilled nursing care).
But what’s not clear is that you often need prior authorization — meaning the plan must approve before you can get care. This can delay treatment or limit your options.
4. Fine Print on Out-of-Network Coverage
PPO (Preferred Provider Organization) plans sometimes say you can see out-of-network doctors.
What’s hidden: out-of-network care usually costs much more (higher copays/coinsurance), and many doctors simply won’t accept the plan at all.
Key Takeaway:
If you’re comparing Medicare Advantage plans, always check:
Provider Directory: Is your doctor/hospital really in-network?
Out-of-Network Rules: What happens if you go outside the network?
Prior Authorization: What services require it?
Star Ratings & Complaints: CMS tracks complaints about misleading marketing.
Can I meet with a Medicare advisor on behalf of my mom and dad?
Yes, you can absolutely meet with a Medicare advisor on behalf of your mom and dad. Many agents work directly with family members to help explain options, compare plans, and make sure everything is set up correctly.Here’s what helps:
• Bring their Medicare card and a list of their medications.
• Know their doctors and any health concerns.
• If you're helping with enrollment or making decisions, the advisor may ask for written permission or a signed form (like an Authorization to Disclose).
This kind of support is common and encouraged, especially when parents prefer someone they trust to help guide the process. Let me know if you’d like help preparing questions or documents for that meeting.
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.
What Medicare penalties are most common?
Here’s a clear breakdown of the most common Medicare penalties people run into:1. Late Enrollment Penalty for Part B (Medical Insurance)
When it happens: If you don’t sign up for Part B when you’re first eligible and don’t have other “creditable” coverage (like group insurance through a job).
The penalty: Your Part B monthly premium goes up 10% for each full 12-month period you were eligible but didn’t enroll.
Duration: You pay this higher premium for as long as you have Part B.
2. Late Enrollment Penalty for Part D (Prescription Drug Coverage)
When it happens: If you go 63 days or more without Part D coverage (or other creditable drug coverage).
The penalty: Your Part D premium increases by 1% of the “national base beneficiary premium” for each month you didn’t have coverage. (This amount can change each year.)
Duration: You pay the penalty for as long as you have Part D.
3. Medicare Advantage (Part C) Late Enrollment Issues
No direct “penalty,” but if you miss your enrollment periods, you may have to wait until the Annual Enrollment Period (Oct 15–Dec 7) to join a plan.
During that wait, you may be left without the coverage you want.
✅ In short:
Part B Penalty = 10% higher premium for every year late.
Part D Penalty = 1% higher premium for every month late.
Part C (Advantage) = Not a penalty, but missed timing can leave gaps in coverage.
When should my plan be reviewed?
The best time to do this is during Medicare’s Annual Enrollment Period (AEP):📅 October 15 – December 7 each year.
During this period, you can:
• Review your current coverage (whether you have Original Medicare + Part D or a Medicare Advantage plan).
• Compare new plan options for the coming year.
• Switch plans, add or drop drug coverage, or move back to Original Medicare.
Any changes you make take effect January 1 of the next year.
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🧭 You should also review your plan anytime your needs or costs change, such as:
• Your medications change or you start a new prescription.
• Your doctors or preferred hospitals are no longer in your plan’s network.
• You move to a new ZIP code or state (this can trigger a Special Enrollment Period).
• Your income changes and you may qualify for Extra Help or a Medicare Savings Program.
• Your plan announces premium or copay increases for the next year.
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Tip:
Even if you’re happy with your plan, check each fall that it still covers your medications, doctors, and pharmacies — plans update their benefits and drug lists every year.
Does Medicare cover Breztri?
Yes — many Medicare Part D and Medicare Advantage plans do cover Breztri.Coverage and cost depend entirely on the plan’s formulary tier, so your copay can vary a lot.
It’s usually a Part D drug.
Some plans put it on a higher tier, which means a higher copay.
Most plans don’t require prior authorization, but some may have limits (quantity limits, step therapy).
AstraZeneca’s $35 cap does NOT apply to Medicare, but you may qualify for their AZ&Me assistance program.
Bottom line: Breztri is generally covered, but what you pay depends on your specific plan. I can check your ZIP code to see which plans in your area cover it the best.
What is the benefit to me if I use your Medicare Referral phone number?
Having a local Medicare agent gives you access to the agent and their knowledge to keep you informed of changes to Medicare and your plan in the ways that it can impact you. Call Centers and Insurance carriers direct are limited in their ability to help individuals. Call Centers are contracted to sell a limited number of plans only for the carriers they contract with, and Carriers are limited to only offering their plans, limiting your access to to all other available plans. Like shopping for a car and going to Ford, who will never tell you about the other brands, regardless if one may better fit for you. Going to medciare.gov shows you all the plans available but you must do all the research yourself and know which plans are contracted which which hospitals and healthcare providers and keep up with the annual changes yourself.Local brokers know the networks, and providers, and can help you find the plan that best fits your needs at the lowest out of pocket costs, and notify you each year if you need to make changes.
Does everyone over the age of 65 qualify for Medicare?
To be eligible for Original Medicare Part A and Part B, you must be age 65 or have been entitled to Social Security Disability insurance for 24 months (two exceptions to this: disabled due to end stage renal disease ESRD or ALS).Part A is hospital insurance and comes with a zero dollar premium if you are insured (e.g. paid FICA tax for 10 years) for Social Security benefits. Many people sign up for Part A, even if they are continuing to work since it is a benefit they have earned and does not cost anything extra. It simply provides extra coverage.
Part B is medical insurance and in 2026 comes with a $202.90 monthly premium for most individuals (some high earners pay pay more for their Part B). If you are still working at age 65 and covered by an employer group health plan (EGHP), many people hold off on signing up for Part B, due to the cost of the premium. There is also no penalty for filing after age 65, if you are covered by an EGHP that is creditable. You should ask your Human Resources Department if your EGHP is creditable before deciding not to take Part B at age 65.
If you have not worked and paid into Social Security and are not insured for benefits, you can get Part A and Part B, but you would owe the monthly premiums for both. For Part A, the monthly premiums may range from ~$300 to over $500 monthly. For Part B, the monthly premium will be $202.90.
I also recommend working with a local Medicare expert at least 4-6 months before your 65th birthday. Additionally, if you are on Social Security Disability, reach out 4-6 months before you are eligible for Medicare. Medicare experts will be able to educate you on all your Medicare options (e.g. Original Medicare, Medicare Advantage Plans, Dental, Vision, Hearing etc...), as well as ensure that you avoid costly late enrollment penalties.
I am on ssi Disability. I turn 65 in June. I also just got Humana health. So does it be change to SSI?? Or does my SSI -Disabiliy just go on til death.
To answer your question, we'll have to make a couple of assumptions first:- If you’ve been receiving SSDI for at least 24 months, you’re already enrolled in Medicare Part A and likely Part B. This is automatic for SSDI recipients, regardless of age.
- Your Humana plan is likely a Medicare Advantage plan (Part C), which replaces Original Medicare (Parts A and B) and may include Part D (prescription drugs)
If these assumptions are correct, at age 65, your Medicare eligibility continues, but your SSDI benefits will probably convert to Social Security retirement benefits. The monthly payment amount typically stays the same, and your Medicare coverage is unaffected. You don’t need to take action for this conversion; the SSA handles it automatically:
- Since you’re likely already enrolled in Medicare due to SSDI, turning 65 won’t require re-enrollment. Your Medicare Part A and Part B (or your Humana Medicare Advantage plan) continue seamlessly.
- If you’re enrolled in a Humana Medicare Advantage plan, it remains active unless you choose to change plans.
That said, turning 65 triggers your Initial Enrollment Period (IEP) for Medicare (3 months before to 3 months after your 65th birthday, April–September 2025). During this period, you can:
- Stay with your current Humana Medicare Advantage plan.
- Switch to another Medicare Advantage plan.
- Return to Original Medicare (Parts A and B) with or without a Part D plan.
I'd be happy to review the details of your specific situation with you to ensure that you get set up with the best plan(s) for your individual needs!
I worked for the federal government for 30 years and took early retirement. How does my federal retirement affect my Medicare options?
Your early retirement from the federal government, specifically under the Federal Employees Retirement System (FERS) or Civil Service Retirement System (CSRS), does not affect your eligibility for Medicare. You are still entitled to enroll in Medicare at age 65, regardless of your retirement status. Your Federal Employees Health Benefits (FEHB) coverage can continue alongside Medicare, or you can choose to enroll in Medicare & potentially adjust your FEHB plan. Here's a more detailed explanation:Medicare Eligibility: Federal employees, regardless of whether they retire early or at the traditional retirement age, become eligible for Medicare at age 65.
FEHB & Medicare: You can choose to keep your FEHB coverage in retirement, & you can also enroll in Medicare Parts A & B.
Coordination of Benefits: If you enroll in both FEHB & Medicare, the two programs will work together to cover your healthcare costs. Medicare will generally be the primary payer for services covered by both programs.
FEHB Adjustments: When you enroll in Medicare, you have the option to adjust your FEHB coverage. You may be able to switch to a different FEHB plan or reduce your coverage, potentially saving on premiums.
Medicare Enrollment Timing: If you're already receiving Social Security or Railroad Retirement benefits when you turn 65, you'll be automatically enrolled in Medicare Parts A & B. If not, you'll need to actively enroll during the designated enrollment periods.
Part A Premium: Most federal employees & annuitants are eligible for premium-free Part A coverage at age 65. Part B Premium: There is a premium for Medicare Part B, which you'll need to pay regardless of whether you have FEHB.
Decision to Enroll: You have the flexibility to decide whether to enroll in Medicare, keep your FEHB coverage, or enroll in a combination of both.
It's recommended to carefully evaluate your options & consider how FEHB & Medicare will work together to meet your specific healthcare & financial needs.
How could a shrinking workforce affect Medicare funding in the next 20 years?
As America’s workforce gets smaller, it can create some real challenges for Medicare over time. Medicare is funded partly through payroll taxes — meaning today’s workers help cover the healthcare needs of today’s retirees. When fewer people are working, there are fewer payroll-tax dollars flowing into the system.Over the next 20 years, this shift could mean:
• More retirees than workers
The number of people aging into Medicare is growing faster than the number of people entering the workforce. That creates a wider gap between how much Medicare pays out and how much it brings in.
• Increased pressure on Medicare’s budget
With fewer workers contributing, Medicare may face financial strain, which could lead to discussions about adjusting taxes, premiums, benefits, or program rules to keep everything stable for future generations.
• Innovation and policy changes
The encouraging news: Medicare has weathered big demographic changes before, and policymakers update the program over time to keep it strong. New technologies, improved healthcare models, and economic growth can also help support the system.
Bottom line: A shrinking workforce can put stress on Medicare’s funding, but the program has a long history of adapting — and seniors today and in the future should expect leaders to continue working to protect this important coverage.
What’s the best Medicare plan for someone with chronic kidney disease?
There isn’t one single “best” Medicare plan for chronic kidney disease — the right choice depends on your medical needs, doctors, and budget. Original Medicare with a Medigap plan can be a strong option because it allows you to see any Medicare-approved nephrologist and helps cover the 20% coinsurance for frequent treatments like dialysis. Medicare Advantage plans, including Chronic Condition Special Needs Plans (C-SNPs), may offer lower upfront costs, extra benefits, and care coordination, but you must use providers in the plan’s network. The most important step is confirming that your kidney specialists, dialysis center, and medications are well covered under whichever plan you choose.
Could Medicare ever adopt a tiered premium system based on lifestyle factors?
While Medicare premiums are currently based primarily on income, particularly for Parts B and D through the Income-Related Monthly Adjustment Amount (IRMAA), there isn't currently a system in place to adjust premiums based on lifestyle factors like smoking or BMI. Introducing such a system would involve significant legal, ethical, and practical considerations regarding fairness, privacy, and the role of health insurance in incentivizing behavior versus providing a safety net. It's a complex issue with ongoing discussions but no current indication of imminent adoption by Medicare.Are there any pointers or suggestions when looking over my ANOC (Annual Notice of Change)?
Yes — your ANOC (Annual Notice of Change) is one of the most important pieces of mail you’ll get from your Medicare plan each year. It explains what’s changing for the upcoming year — things like your premiums, copays, drug coverage, and extra benefits.When you look it over, take a few minutes to make sure your monthly premium and maximum out-of-pocket costs aren’t increasing too much. Also check the copays for hospital stays and specialist visits, since those can change year to year and really affect what you’ll pay if you need care. Make sure your prescriptions are still covered at the same cost, and that your doctors and preferred hospitals are still in-network. It’s also a good time to review any dental, vision, or other extra benefits to see if anything was added, removed, or reduced.
If you notice anything that could impact your coverage or costs, it’s worth scheduling a quick plan review with an agent before the Annual Enrollment Period (Oct 15–Dec 7) to make sure you’re still in the plan that fits you best.
Is there a Medigap Plan company with a non-increasing premium? I heard Blue Cross/Blue Shield Offers this. If so, how expensive is it?
No Medigap plan company, including Blue Cross Blue Shield, offers a premium that never increases. Premiums typically rise over time due to factors like risk and inflation. Blue Cross Blue Shield does offer reputable Medigap plans, but their premiums generally increase annually based on age and other factors. The cost varies widely, averaging around $189 per month at age 65, but can range from about $60 to over $350 depending on plan type and location.
Isn't it time for Medicare to completely overhaul how it approaches senior care?
Yes, many experts and advocates believe it is time for Medicare to undergo a significant overhaul in how it approaches senior care. While Medicare has been a lifeline for millions of older Americans, several critical issues point to the need for reform.Fragmentation of Care
Medicare often treats conditions and services in silos—hospital care, physician services, home care, etc.—with poor coordination between them. Seniors with chronic or multiple conditions can experience disjointed care and repetitive services.
Solution: Move toward integrated, value-based care models like Medicare Advantage (MA) plans or Accountable Care Organizations (ACOs), but with stronger oversight and transparenc
Inadequate Long-Term Care Coverage
Medicare does not cover most long-term care services, such as help with bathing, dressing, or eating—support that’s vital for many seniors.
Result: Seniors often deplete their savings and turn to Medicaid for long-term care, creating both personal and systemic financial strain.
Solution: Incorporate long-term support services into Medicare—either through new benefits or a hybrid public-private solution.
Underinvestment in Preventive and Home-Based Care
While preventive services are covered, Medicare still leans heavily toward reactive, acute care. Seniors would benefit from stronger support for preventive, home-based, and palliative care.
Solution: Expand coverage and reimbursement for home-based primary care, telehealth, and geriatric care teams.
Mental Health & Social Isolation
Medicare has limited mental health coverage, and many seniors suffer from depression, dementia, and loneliness, which can worsen physical health.
Solution: Increase access to mental health professionals, community-based support, and addrss social determinants of health
Medicare Advantage Oversight
MA plans are growing fast, but some prioritize profi
How might artificial intelligence change how Medicare approves claims in the future?
Artificial intelligence is likely to play a significant role in how Medicare processes and approves claims in the future. AI could help speed up the review process by rapidly analyzing large amounts of data to detect patterns, flag potential fraud, and ensure claims comply with coverage guidelines. This could result in faster approvals and fewer delays for people waiting for critical care or reimbursement.However, it is critical to strike a balance between efficiency and accuracy. Human oversight will still be required, particularly in complex cases, to ensure that people are not unfairly denied coverage. Overall, AI has the potential to improve the system's efficiency and responsiveness.
What are some ways patients can reduce medication costs while on Medicare?
That is an excellent and important question. Navigating prescription costs on Medicare can be complex, but there are several major strategies and programs people can use to significantly reduce their out-of-pocket expenses.Here are the most effective ways to reduce medicine costs while on Medicare:
1. Enroll in "Extra Help" (Low-Income Subsidy - LIS)
This is the single most impactful program for people with limited income and resources.
What it is: A Medicare program (also called the Low-Income Subsidy, or LIS) that helps pay for Part D prescription drug plan costs, including premiums, deductibles, and co-pays.
Benefits: If you qualify, your costs will be capped at very low amounts for both generic and brand-name drugs, and your Part D deductible is eliminated or greatly reduced.
How to Qualify: Eligibility is based on income and assets. You automatically qualify if you have full Medicaid, are in a Medicare Savings Program, or receive Supplemental Security Income (SSI). Otherwise, you can apply through the Social Security Administration (SSA).
2. Compare and Switch Part D Plans Annually
Your current Part D plan might no longer be the most cost-effective option for your specific medications.
Annual Enrollment: Every year (October 15 – December 7), you should use the official Medicare Plan Finder tool on Medicare.gov to compare all available plans.
Check the Formulary: Always check a plan's formulary (its list of covered drugs) to ensure your specific medications are covered and which tier they fall into (lower tiers mean lower out-of-pocket costs).
Lower Premiums vs. Lower Drug Costs: A plan with a lower monthly premium might have a higher deductible or higher co-pays for your specific drugs, making it more expensive overall. Focus on the lowest total annual cost for your medications.
3. Talk to Your Doctor and Pharmacist
Simple conversations can often lead to immediate savings.
Switch to Generics: Ask your doctor if a generic version.
How might climate change-related health issues (like heat stroke) influence Medicare policies?
Centers of Medicare and Medicaid Services or CMS may be prompted by legislative or executive action to create strategies in response to health issues. For example, when COVID-19 impacted the United States, telehealth was implemented to allow Medicare Beneficiaries to still connect with a medical professional without possible exposure to COVID-19.Medicare could use costs and utilization data to monitor geographical areas to see if there are needed adjustments or potentially adjustments in reimbursement models. If it is due to heat stroke, maybe there is a potentially higher reimbursement to address health conditions during summer months.
It is also possible there may be a look at ways to implement more preventative care measures to keep medical costs low.
Chronic special needs plans may become more prevalent in Medicare Advantage Plans (Part C) as various climate conditions could cause serious or chronic conditions to intensify such as cardiovascular issues or respiratory illnesses.
Do Maximum Out-of-Pocket (MOOP) limits change every year?
Yes, Maximum Out-of-Pocket (MOOP) limits can change every year.These limits depend on your specific plan; Medicare Advantage plans can adjust their limits annually as long as they stay below the federal limit. For 2026, the highest a Medicare Advantage plan can set this limit for in-network care is $9,250.
Similarly, Part D plans have their own mandatory out-of-pocket cap, $2,100 for 2026. This means that once you reach these limits, the plan pays 100% of your covered costs for the rest of the year.
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.
Does the SOA need to be completed by a licensed agent, or can administrative staff complete it on the agent’s behalf before the agent contacts the client? This question specifically refers to clients in the USVI.
For the U.S. Virgin Islands, the Scope of Appointment (SOA) must be completed by a licensed insurance agent. Administrative staff cannot fill it out on the agent’s behalf before contacting the client.CMS guidance requires that the agent personally obtains the client’s agreement to discuss Medicare Advantage and/or Part D plans, to ensure compliance and documentation accuracy.
What is Medicare Part B?
Medicare Part B is an optional program that generally covers 80% of approved medical services after an annual deductible. If you are actively working and have creditable employer coverage, you may be able to delay Part B enrollment without penalty.For most people, Part B requires a monthly premium, which is higher for individuals with higher incomes.
You can enroll in Part B during your Initial Enrollment Period, which runs from three months before your birth month through three months after your birth month.
If you miss this window and do not have other creditable coverage, you must wait until the General Enrollment Period (January 1–March 31). Coverage will begin the first day of the month after you enroll, and you may be subject to a late enrollment penalty.
Does Medicare pay for hip, knee, or shoulder replacement surgery?
This is where terminology can get mixed up, and plan specifics are important. Some folks ask, does "Medicare" pay... but they could mean, Original Medicare, A+B, Medicare Advantage Plans | Part C", or a Medicare Supplement (Medigap) Plan.That's why it's so important to speak with a reputable independent broker, but I'll answer as best as possible without that further clarification.
If as an outpatient surgery, which most hip, knee, and shoulder replacements fall under, Medicare Part B would pay 80% of the cost. The other 20% would be on the beneficiary. That would be a sizeable bill, hence why so important to get additional coverage.
If as an outpatient surgery, under a Part C or Medicare Advantage plan, if in-network, you would likely have a flat co-pay. In the states where I write plans, the co-pay is about $300 per surgery. Not a bad deal for a $0 dollar premium Medicare Advantage plan.
If as an outpatient surgery, with Original Medicare Part A + B, plus a Medicare Supplement, depending on how comprehesive the Supplement is (F, G, N, etc.) you will likely have no co-pay. Medicare Part B will cover 80%, and your Supplement will cover the 20% balance.
How can I make sure my Medicare plan will cover future treatments for my illness?
The best way to prepare is to review your plan’s coverage rules, provider network, and prior authorization requirements before making changes. Ask your doctor which treatments you may need in the future and confirm they are covered under your Medicare plan. If you have a Medicare Advantage plan, verify that your specialists, hospitals, and medications are all in-network and on the formulary. For ongoing or complex conditions, some people prefer Original Medicare with a Medigap plan because it offers broader provider access and fewer coverage restrictions.
What’s the best time of year to change my Medicare plan if I develop a new diagnosis?
The best time to review your Medicare coverage after a new diagnosis is right away — but whether you can actually change plans depends on the type of Medicare coverage you have and whether you qualify for an enrollment period.A new diagnosis by itself does not always create an automatic opportunity to change Medicare plans.
For many people, the main time to change Medicare Advantage or Part D coverage is Medicare Open Enrollment, which runs October 15 through December 7 each year. Changes made during that time generally begin January 1.
If you already have a Medicare Advantage plan, you may also have a one-time opportunity to make certain changes during the Medicare Advantage Open Enrollment Period from January 1 through March 31.
In some situations, a new diagnosis may make it worth checking whether you qualify for a Special Needs Plan, often called an SNP. These plans are designed for people with certain chronic conditions, people who qualify for both Medicare and Medicaid, or people who meet certain institutional care requirements. Availability depends on your location and eligibility.
The important thing is not to wait until a crisis. If you receive a new diagnosis, review your doctors, specialists, prescriptions, treatment locations, prior authorization rules, and out-of-pocket costs as soon as possible. Then confirm whether you have an enrollment window available before making any changes.
Shouldn't Medicare expand to cover more alternative treatments that actually help seniors?
That’s a question a lot of people are asking right now.Medicare’s coverage decisions are usually based on whether a treatment is considered “medically necessary” and supported by strong clinical evidence. Some alternative treatments don’t get covered because Medicare requires large-scale studies showing safety and effectiveness.
That said, Medicare has expanded certain benefits over time — for example, it now covers some acupuncture for chronic low back pain and certain preventive services that weren’t included years ago.
If there’s a specific treatment you’re wondering about, I can help you check whether Medicare covers it, whether a Medicare Advantage plan offers it as an extra benefit, or what other options might help reduce the cost.
What treatment were you thinking about?
Does original Medicare require referrals before visits to specialists?
No, Original Medicare (Part A and Part B) generally does not require a referral to see a specialist. As long as the specialist accepts Medicare patients, you can usually schedule an appointment directly. However, some Medicare Advantage (Part C) plans, especially HMOs, may require referrals from your primary care doctor before seeing certain specialists.
Does Medicare pay for IV chemotherapy?
Original Medicare covers medically necessary injectable and infusion chemotherapy medication if administered in a hospital setting and ordered by your healthcare provider as long as the drug is FDA approved for the condition you are being treated for. If you have a medicare advantage plan you will have a 20% copay. If you have a medigap supplement plan original medicare will cover the first 80% and your supplement plan will cover the remaining 20% once you have satisfied the annual deductible.
Which states have the best Medicare policies?
When evaluating the best states for Medicare policies, consider factors like affordability, plan quality and availability. Here are some top states based on these criteria:Top 5 States with High-Quality Medicare Plans:
• Montana: 96.3% of Medicare Advantage plans are rated 4 stars or higher, with an average monthly premium of $46.36
• Wyoming: 88.1% of plans are highly rated, with an average premium of $49.13
• West Virginia: 79.7% of plans are highly rated, with an average premium of $17.77
• Iowa: 77% of plans are highly rated, with an average premium of $10.07
• South Dakota: 73.9% of plans are highly rated, with an average premium of $42.06
States with Affordable Medicare Plans:
• Florida: Average monthly premium of $1.09
• Texas: Average monthly premium of $4.99
• Nevada: Average monthly premium of $3.09
• Rhode Island: Average monthly premium of $4.56
• Louisiana: Average monthly premium of $5.95
States with Low Out-of-Pocket Costs:
• California: Average in-network out-of-pocket spending limit of $3,884.44
• Florida: Average out-of-pocket spending limit of $4,043.15
• Illinois: Average out-of-pocket spending limit of $4,926.67
• Kansas: Average out-of-pocket spending limit of $5,190.25
• Missouri: Average out-of-pocket spending limit of $5,256.31
Keep in mind that Medicare policies and costs can vary significantly depending on your location, even within states. It's essential to research and compare plans specific to your area to find the best fit for your needs and budget.
What's the projected impact of an aging population on Medicare Part A hospital funds?
Answer from Janix Barbosa-Llanos, MBA, PMP, CEP, RSSA, FSN(Licensed Insurance Agent — For Educational Purposes Only)
During our working years, we pay Medicare taxes that go into the Hospital Insurance (HI) Trust Fund, which helps cover inpatient hospital, skilled nursing, hospice, and limited home health care. The program works on a pay-as-you-go basis—today’s workers fund current retirees.
As people live longer and fewer workers pay into the system, pressure on the Part A fund grows. About 10,000 Americans turn 65 every day, and the cost of care increases with age and chronic conditions.
According to the 2025 Medicare Trustees Report, the HI Trust Fund is expected to remain solvent until 2033. After that, if no policy changes occur, incoming revenue would cover roughly 89 % of projected costs.
The good news: current beneficiaries are not affected. Medicare continues to pay for covered hospital services as usual. The solvency discussion is about long-term sustainability, not today’s coverage.
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Medicare / CMS Disclosure
For educational purposes only. Not affiliated with or endorsed by Medicare or any government agency. Plan availability and benefits vary by ZIP code and individual eligibility.
References:
2025 Medicare Trustees Report, page 6; Committee for a Responsible Federal Budget, June 2025.
Why do my copays or premiums look different in January?
Annual plan changes – Every January, many Centers for Medicare & Medicaid Services Medicare Advantage and Medicare Part D plans update their premiums, copays, deductibles, and drug formularies for the new plan year.Deductibles reset – Most annual deductibles start over on January 1. Until you've met your deductible, you may pay more for doctor visits, hospital care, or prescriptions.
Premium adjustments – Your monthly premiums for Medicare, Medicare Advantage, Part D, or supplemental coverage may increase or decrease based on the new year's rates.
Prescription drug coverage changes – Your medications may move to a different formulary tier, resulting in higher or lower copays. Pharmacy networks can also change from year to year.
Always read your Annual Notice of Change (ANOC). It explains any changes to your premiums, copays, deductibles, and covered medications before the new plan year begins.
If I switch plans to cover a brand-name eye drop my current plan won’t cover, but my new doctor later takes me off that medication after open enrollment ends, do I have any way to change my plan again?
Short answer:Usually no. Once the Medicare Open Enrollment Period (Oct 15 – Dec 7) ends and your new coverage starts on January 1, you generally cannot change plans again just because your doctor stops the medication.
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When you could change plans again
There are only a few exceptions called Special Enrollment Periods (SEPs) or the Medicare Advantage Open Enrollment Period:
1) Medicare Advantage Open Enrollment (Jan 1 – Mar 31)
If you enrolled in a Medicare Advantage plan, you get one extra change:
• Switch to another Medicare Advantage plan or
• Drop MA and return to Original Medicare (and possibly add Part D)
But you can only use this once per year, and not if you’re already in Original Medicare with Part D.
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2) Special Enrollment Periods (SEPs)
You may change plans outside enrollment only if you qualify for special situations, such as:
• Moving out of your plan’s service area
• Qualifying for Medicaid or Extra Help
• Losing other creditable drug coverage
• Plan contract changes or termination
Medication changes alone do NOT qualify for an SEP.
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Bottom line for the senior’s situation
• Switching plans for a specific drug is allowed during Open Enrollment.
• If the doctor later stops that drug after enrollment ends, the person usually must stay in the new plan until the next Open Enrollment—
unless they qualify for:
• The Jan–Mar Medicare Advantage Open Enrollment, or
• A Special
How do I handle billing issues if something is wrong on a Medicare statement?
If you notice something wrong on your Medicare statement, start by reviewing your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) carefully. Then:Contact your provider or supplier first – Many billing errors are simple mistakes that can be corrected quickly.
If it’s not resolved, call 1-800-MEDICARE to report the issue.
Keep detailed notes – Record dates, names, and what was discussed.
If you suspect fraud, contact the Medicare Fraud Hotline or your State Health Insurance Assistance Program (SHIP) for help.
👉 Always keep copies of your bills and statements until the issue is resolved.
What role might private insurers play if Medicare expands to cover more preventive care?
If Medicare expands to cover more preventive care, private insurers—particularly those involved in Medicare Advantage and Medigap—would likely adjust their roles and offerings in several key ways:🔹 1. Medicare Advantage (MA) Plans: Adaptation & Competition
Private insurers offering Medicare Advantage (Part C) plans would need to adapt to the new baseline of expanded preventive services in traditional Medicare.
Competitive Response: MA plans already include preventive care benefits and often go beyond traditional Medicare. If traditional Medicare expands its preventive care offerings, MA plans may need to add new perks or enhanced services (e.g., fitness programs, dental, vision) to remain competitive.
Cost Management: More preventive care could lead to lower long-term costs (e.g., fewer hospitalizations), which may allow MA plans to reallocate resources or offer lower premiums or more generous coverage.
Risk Adjustment: Insurers might revise how they manage risk and stratify populations, since better preventive care could change the health profile of enrollees over time.
🔹 2. Medigap (Supplemental Insurance): Shrinking Value Proposition
Medigap policies help cover out-of-pocket costs in traditional Medicare, but preventive care is typically covered in full by Medicare already.
Reduced Need: If Medicare expands its preventive coverage, the need for Medigap to help pay for these services declines, potentially reducing demand for Medigap policies.
Shifting Product Offerings: Insurers might pivot to offering value-added services or reframe Medigap as covering catastrophic events or chronic care support, rather than day-to-day or preventive needs.
🔹 3. Policy Design & Lobbying
Private insurers may seek to influence the scope and implementation of expanded preventive care policies.
Advocacy: They may lobby for inclusion of digital health tools, telehealth services, or chronic care management as part of "preventive" care.
How much is spent on healthcare per year the U.S., and what does this amount represent per person?
Healthcare represents 17.6% GDP (gross domestic product) which represents the percentage of the total US economy. These statistics available are from 2023 with anticipated or projected increases.Medicare spending represents the single largest component of government healthcare expenditure, with Medicare spending growing 8.1% to $1,029.8 billion in 2023, representing 21 percent of total National Health Expenditures. This substantial growth reflects both demographic shifts toward an aging population and increased utilization of medical services among Medicare beneficiaries. The program’s expansion demonstrates the federal government’s commitment to providing comprehensive healthcare coverage for seniors and disabled Americans.
In 2023 $4.9 Trillion was spent for healthcare (7.5% increase over 2022) with $14,570 per person (per capita) spent for each individual. Let's break that HUGE number down even more:
Medicare Spending (2023) | $1.03 Trillion | 8.1% annual growth
Medicaid Spending (2023) | $871.7 Billion | 7.9% annual growth
Private Insurance Spending (2023) | $1.46 Trillion | 11.5% annual growth
Hospital Expenditures (2023) | $1.52 Trillion | 10.4% annual growth
Prescription Drug Spending (2023) | $449.7 Billion | 11.4% annual growth
How to enroll in Part D plan for RX coverage?
You can enroll in a Medicare Part D plan through the Medicare.gov website. You will want to be careful and make sure you verify that all of your medications are covered and compare your out-of-pocket costs between plans as they will vary. Also make sure your preferred Pharmacy is in network as well. Even though the insurance carriers no longer compensate Medicare Health Insurance Agents to enroll Medicare beneficiaries into their Part D Plans, some agents may be willing to offer their time and expertise in finding a plan that fits your needs. This process can be time consuming if you have a lot of prescriptions, so start early and be sure to have an organized list of your prescriptions and the dosages ready to enter when you do your research. Remember, not signing up for Medicare Part D when you are eligible even if you don’t have any prescriptions will result in a late penalty when you sign up later on down the road.
Are cataract surgeries covered by Medicare?
Here’s an updated version with that note included:Medicare generally covers cataract surgery under Part B when the procedure is considered medically necessary due to vision problems affecting daily activities like driving, reading, or ability to work. Coverage typically includes the surgery itself, the surgeon and facility fees, anesthesia, a standard lens, and follow-up care. After the Part B deductible is met, Medicare usually pays 80% of the approved amount, leaving the beneficiary responsible for the remaining 20% unless they have supplemental coverage.
Medicare also covers one pair of standard eyeglasses or contact lenses after cataract surgery with an implanted lens. However, premium upgrades or certain laser-assisted procedures are often not fully covered and may result in additional out-of-pocket costs. Individuals with a Medicare Supplement plan may have little to no cost-sharing, while those enrolled in a Medicare Advantage plan may have specific copays, coinsurance, and network requirements depending on the plan.
Overall, cataract procedures are generally covered pretty well for Medicare beneficiaries, however, it is important to review each plan’s Summary of Benefits and Evidence of Coverage to understand how cataract surgery, outpatient procedures, and lens upgrades are covered under that specific plan.
Do I need a doctor’s referral for Medicare to cover therapy?
depends entirely on which type of Medicare plan you have and the type of therapy you are seekingOriginal Medicare generally does not require a referral to see specialists, including therapists, as long as the provider accepts Medicare assignment
If you have a Medicare Advantage (MA) plan, the rules are different and vary significantly by plan type:
HMO (Health Maintenance Organization) : Yes, typically required. HMOs almost always require you to get a referral from your Primary Care Physician (PCP) to see a specialist or therapist, and you must use in-network providers
PPO (Preferred Provider Organization) : Often not required. PPOs typically do not require referrals, but you will pay significantly less if you use in-network providers.
PFFS (Private Fee-for-Service): Usually not required.
How much will the monthly premium for Medicare Part B be in 2026, and what drives those changes?
💰 2026 Medicare Part B Monthly PremiumStandard Part B premium for 2026: $202.90 per month for most beneficiaries. That’s up from $185 in 2025 — about a $17.90 increase or ~9.7%
📊 What drives the change in Part B premiums?
Medicare Part B premiums aren’t arbitrary — they’re based on the projected cost of providing Part B services and how much those costs are expected to rise. The main drivers include:
1️⃣ Healthcare cost trends
CMS projects higher healthcare prices and increased utilization of doctor services, outpatient care, and equipment — and Part B premiums are set to cover roughly 25% of the Part B program’s costs. When expected costs go up, premiums go up too.
2️⃣ Utilization assumptions
More people using services — especially more expensive services — drives higher projected payouts from Medicare. Premiums adjust to reflect that trend.
3️⃣ Policy factors
Some policy decisions can nudge premium trends. For example, CMS noted that changes to spending on certain products (like skin substitutes) slightly reduced the expected premium increase for 2026 compared with what it would have been otherwise.
4️⃣ Income-related surcharges (IRMAA)
This isn’t a “cost of care” factor, but higher earner premiums are set by law. If a beneficiary’s income is above certain IRS thresholds, Social Security adds an IRMAA surcharge on top of the standard premium.
How long do Medicare appeals take?
There are several levels of Medicare appeals.The first level appeal is a "Redetermination". This can take up to 60 days once Medicare receives your appeal.
The second level is a "Reconsideration". This can also take up to 60 days.
Next, the third level, is a "Hearing before an Administrative Law Judge". This is supposed to be 90 days, but a backlog of cases actually makes it longer. It could be months or a year.
The fourth level is a "Medicare Appeals Council Review". Again this is 90 days from receipt of the request.
Finally, the fifth level is going to "Federal District Court". This process could take months to years.
Why do people still get large medical bills even with Medicare?
Big medical bills still happen with Medicare because:• No cap on cost-sharing – Original Medicare pays 80% of most doctor and outpatient bills, but the patient owes the other 20% with no yearly limit, unless they have a supplement plan.
• No supplement or Medicare Advantage plan – Original Medicare by itself was never designed to limit how much someone pays in a bad year.
• Going outside the plan’s network – common with Medicare Advantage plans, which can charge a lot more (or pay nothing) for out-of-network care.
• Services that just aren’t covered – dental, vision, hearing aids, and long-term nursing home care are mostly not covered at all.
• Nursing home stays – Medicare only fully covers the first 20 days in a nursing facility after a hospital stay. Days 21 through 100 require a daily payment from the patient, and after 100 days the patient pays the entire cost.
• Prescription drug costs – even with a drug plan, certain medications or spending levels can still mean high out-of-pocket costs.
I will turn 65 in June 2026 and currently receive SSI and Medicaid. Will I automatically get Medicare, can I keep both Medicare and Medicaid, do I qualify for QMB due to low income, and why am I receiving so many application notices?
1. Automatic Enrollment in MedicareBecause you receive Supplemental Security Income (SSI), your enrollment in Medicare is generally automatic when you turn 65.
When it starts: Your Medicare Part A (Hospital Insurance) and Part B (Medical Insurance) will begin on the first day of the month you turn 65 (June 1, 2026).
What to expect: The Social Security Administration (SSA) will automatically enroll you, and you should receive your red, white, and blue Medicare card in the mail about 3 months before your 65th birthday.
2. Keeping Both Medicare and Medicaid (Dual Eligibility)
Yes, you can absolutely keep both. Individuals who qualify for both programs are known as "dual eligibles." * How they work together: Medicare will become your primary insurance (paying first for your medical care), and Medicaid will act as your secondary insurance, covering costs that Medicare leaves behind, such as deductibles, copays, and coinsurance.
Prescription Drugs: Once you have Medicare, your prescription drug coverage will shift from Medicaid to a Medicare Part D plan. Because you have SSI and Medicaid, you will automatically qualify for Extra Help, a federal program that helps pay for your Part D premiums, deductibles, and lowers your medication copays.
3. Qualifying for the Qualified Medicare Beneficiary (QMB) Program
Since you are already receiving SSI and Medicaid, it is highly likely that you will automatically qualify for a Medicare Savings Program (MSP), specifically the Qualified Medicare Beneficiary (QMB) program.
What QMB does: The QMB program is a state Medicaid program that pays for your Medicare Part B monthly premiums. It also legally prohibits doctors and providers who accept Medicare from billing you for Medicare-covered deductibles, copayments, and coinsurance.
The Process: In many states, if you already have full Medicaid and SSI, you are automatically transitioned into the QMB category when Medicare starts.
Does Medicare part A and B cover urgent care office visits?
Yes, urgent care visits are covered, but they are covered specifically by Medicare Part B (Medical Insurance), not Part A.Here is the breakdown of how coverage and costs work for 2025:
Part B Covers the Visit: Medicare Part B covers urgent care visits for non-life-threatening illnesses or injuries (like a flu, small wound, or earache) that require immediate attention.
Part A Does Not Apply: Part A generally only covers inpatient hospital stays. Unless you are transferred from urgent care and admitted directly into a hospital as an inpatient, Part A will not pay for the visit.
Your Costs for Urgent Care (in 2025)
If you have Original Medicare (Part A and Part B), you will pay the following for an urgent care visit:
Part B Deductible: You must pay the first $257 of medical costs for the year (if you haven't met this deductible yet).
Coinsurance (20%): Once the deductible is met, you pay 20% of the Medicare-approved amount for the visit and any services received (like X-rays or stitches).
Copayment: You may also be charged a fixed copayment depending on the specific facility's rules and if the visit takes place in a hospital outpatient setting.
Important Note: To avoid higher costs, you should verify that the urgent care center accepts Medicare assignment. If they do not, they may charge you up to 15% more than the Medicare-approved amount (known as an "excess charge").
Which Medicare plans offer support for arthritis or chronic pain management?
Original Medicare (Parts A and B) and Medicare Advantage (Part C) both offer comprehensive support for arthritis and chronic pain lasting longer than 3 months. Specific covered benefits include: Chronic Pain Management: Outpatient monthly services including pain assessment, medication management, and care coordination (covered under Medicare Part B). Therapies: Physical and occupational therapy, chiropractic services, and acupuncture for lower back pain. Specialized Plans: Medicare Chronic Special Needs Plans (C-SNPs) for rheumatoid arthritis, which tailor benefits and care teams to your exact condition. Medications: Outpatient medications are covered through Medicare Part D or Medicare Part B depending on how they are administered (e. g., self-administered pills vs. doctor-injected biologics). If you want me to look up plans in your area, please contact me
What happens if my specialist leaves the network in the middle of the year?
You have a few options:- Remain with the specialist and request an out of network exception through the carrier/plan when there is a medical necessity, lack of other specialist in the network within a reasonable distance, and for continuity of care;
- Remain with the specialist and assume out of network costs;
- Visit the member service website/portal to identify a specialist that is in network and accepting new patients (the website will have the most up to date information regarding in-network providers);
- Call your Trusted, Advisor and Medicare Agent for Support and Guidance;
- Contact member services for a recommendations of available in network specialist;
- or Notify your primary care provider and see who they recommend as part of their preferred referrals/specialist within the shared network of your plan.
The goal is minimize any disruption in care and treatment. Your agent and plan will help you navigate all available options and help you identify the best solution.
How do Medicare agents and brokers get paid?
Independent Medicare agents and brokers like myself are paid commissions by the insurance companies, not by Medicare itself.There are two main types of payments:
Initial Commission- this is paid when you enroll a new client in a Medicare Advantage, Medigap, or Part D plan. It’s the largest payment an agent receives. The higher initial commission exists because that’s when the agent does the most work, takes on the most risk, and incurs the highest costs. It’s designed to compensate for that front-loaded time and effort.
Renewal Commission- this is a much smaller ongoing payment the agent receives each year the client stays on that plan. Renewals are where agents make most of their long-term income.
Why There’s Little Incentive to Push One Carrier Over Another:
Commissions are largely standardized. Medicare Advantage and Medigap commission rates are very similar across most major carriers. An agent usually makes roughly the same amount whether the client picks Carrier A or Carrier B.
CMS (the government agency that oversees Medicare) sets guidelines on commission amounts to prevent agents from steering clients toward one company just because it pays more.
While there can be small differences between carriers, they’re usually not big enough to make a meaningful impact on an agent’s income.
Some carriers occasionally offer bonuses or overrides for high sales volume, but these are based on overall production — not on pushing one specific plan over another.
What actually motivates GOOD agents?
Client retention- Recommending a poor-fitting plan just to make a slightly higher commission usually backfires when the client is unhappy and leaves.
Referrals- Satisfied clients refer friends and family.
Bottom line, most Medicare agents make similar money regardless of which carrier a client chooses. The real incentive is keeping clients happy and on a plan that actually works well for them, not steering them toward one specific
Can you get Medicare without Social Security?
Yes, you can apply for Medicare benefits without starting your Social Security benefits. In that case, you would be responsible for paying your Part B premium directly until you begin collecting Social Security, at which time the premium is typically deducted from your monthly benefit. You would also need to pay a premium for Medicare Part A if you have not earned the required 40 quarters of paying into Social Security through work history.How long after I apply for Medicare A&B will I receive my Medicare card?
There’s no definitive answer, but in general the typical time is between 3-6 weeks. Allow 2-4 weeks for application processing (it’s faster if you apply in person or online) and about 2 weeks for the physical card to be delivered. Your number should be available online immediately after approval, and you don’t need your physical card to apply for your supplemental coverage. You just need the number (your agent will still verify eligibility in the system).The fastest way to check status is through a my Social Security account:
(https://www.ssa.gov/myaccount) or by calling the SSA.
How could a universal healthcare debate shift Medicare's structure in the next decade?
Great question — and here's the simple breakdown from a seasoned Medicare agent’s point of view:If the U.S. ever moved toward universal healthcare — meaning everyone gets health coverage from the government — it could majorly shift how Medicare works. Here’s how:
Medicare could expand to cover everyone — This is the “Medicare for All” idea. Instead of just covering people 65+ or those with disabilities, Medicare could become the national health insurance program for all Americans.
Private Medicare Advantage plans might shrink or go away — If the government runs everything, private insurers might play a smaller role. Or, they could shift to offering optional add-on coverage, kind of like how dental or vision works now.
Benefits could change — Depending on the model, we could see more services covered (like dental, vision, long-term care), or there could be stricter cost controls to make the system affordable for everyone.
Taxes might replace premiums — Instead of paying monthly Medicare premiums, people might see higher payroll or income taxes to fund the system — but with fewer out-of-pocket costs at the doctor or hospital.
Bottom line: If universal healthcare becomes reality, Medicare could grow into a much bigger program — but with big changes to how it’s funded, who it covers, and what it looks like. No one knows for sure yet, but as always, I’ll be here to help you adjust if and when it happens.
I start Medicare in 2026 and a one-time 401(k) withdrawal in 2024 placed me in the second IRMAA tier for part of that year. When should I file Form SSA-44 so my 2027 premium returns to the lowest tier?
You should file Form SSA 44 in 2026, after you are enrolled in Medicare and after Social Security issues your IRMAA determination for 2027. IRMAA always looks back two years, so your 2027 premiums are based on your 2025 tax return, not the one time 401(k) withdrawal you took in 2024. Social Security will first send an IRMAA notice if they believe higher income still applies, and only then can SSA 44 be used to correct it. Filing earlier does nothing because the form is corrective, not proactive. Once you receive the 2027 IRMAA notice in 2026, submit SSA 44 right away with documentation showing the withdrawal was a one time event and that your income has returned to normal, which should restore your Part B and Part D premiums to the lowest tier.
How often can I get mammograms, colonoscopies, or prostate tests?
Medicare Part B covers screening mammograms once every 12 months for women age 40 and older, and one baseline mammogram for women ages 35–39.Colonoscopy screenings are covered every 10 years for people at average risk, or every 24 months if the person is at high risk for colorectal cancer.
For prostate cancer screening, Medicare covers a PSA blood test once every 12 months for men age 50 and older, and a digital rectal exam once every 12 months (the exam usually has a 20% coinsurance).
How has the push for healthcare price transparency affected your work as a Medicare Agent? What's one unexpected outcome you've observed?
The push for healthcare price transparency has transformed the way I work as a Medicare agent. Clients are no longer just asking which plan covers their prescriptions—they’re asking how negotiated rates compare across providers and what their true out-of-pocket costs will be. It’s made my role more consultative and educational, which I welcome.One unexpected outcome? Some clients have become incredibly savvy—almost like amateur billing analysts. They’re cross-referencing hospital pricing data with their Explanation of Benefits and even challenging discrepancies. It’s a shift I didn’t anticipate, but it’s empowering. People are finally feeling like they have a seat at the table when it comes to their healthcare decisions.
How is automation improving efficiency and compliance in Medicare processes?
Automation, particularly through Agentic AI and Robotic Process Automation (RPA), is drastically reducing the "administrative tax" on healthcare providers.• Accelerated Prior Authorizations: Under the 2026 CMS Interoperability and Prior Authorization rule, payers must respond to standard requests within 7 days and expedited ones within 72 hours. Automation makes this possible by:
• Auto-Intake: Transforming faxed or PDF forms into structured data instantly.
• Clinical Matching: Using AI to compare patient data against payer-specific guidelines in real-time.
• Reduced Billing Errors: Platforms are now achieving up to a 30–40% reduction in billing errors. AI "scrubs" claims before submission to ensure they align with the latest Medicare Physician Fee Schedule (MPFS) codes.
• Predictive Denial Management: Instead of reacting to a rejection, AI models now predict the likelihood of a denial before a claim is submitted, allowing teams to fix documentation gaps proactively.
Do IRA or 401(k) withdrawals increase Medicare costs?
Yes. Withdrawals from traditional IRA or 401(k) accounts count as taxable income, which can increase your Medicare premiums through IRMAA.Medicare looks at your income from 2 years prior, so even a large one-time withdrawal can raise your Part B and Part D costs for a year.
Note: Roth IRA withdrawals (if qualified) typically don’t count toward Medicare income.
Is there a penalty for Medicare Part A or B for a 65-year-old green card holder who hasn’t met the five-year U.S. residency requirement and has no other insurance?
No, there is no penalty for not having Medicare at age 65 if you do not yet meet the residency requirement.Medicare penalties only begin to accrue once you are eligible to enroll and choose not to. Since a green card holder is generally not eligible for Medicare until they have lived in the U.S. continuously for at least five years, the "penalty clock" does not start until that five-year mark is reached.The Rules for Your SituationEligibility Gap: As a green card holder, you must be 65 or older and have 5 years of continuous U.S. residency to qualify for Medicare.No "Pre-Eligibility" Penalty: You cannot be penalized for not having a service you aren't legally allowed to buy yet.When the Penalty Starts: Once you hit your 5th anniversary of residency, your Initial Enrollment Period begins. If you do not sign up at that time (and don't have other "creditable" coverage like a job-based plan), you will then face lifetime late-enrollment penalties for Part B and Part D.Important ExceptionsThere is one major way you might be eligible before the five-year mark:Spousal Credits: If you have been married for at least one year to a U.S. citizen or green card holder who is at least 62 and has worked in the U.S. for 10 years (40 quarters), you may be able to qualify for Medicare based on their work record. In this specific case, the five-year residency rule is waived.What should you do in the meantime?Since you are currently ineligible for Medicare, you may want to look into:The Health Insurance Marketplace: Lawfully present immigrants can purchase plans through the ACA Marketplace (Healthcare.gov) even if they haven't been here for five years. You may even qualify for subsidies depending on your income.Short-Term "New Immigrant" Insurance: Some private companies offer temporary medical insurance specifically for new green card holders waiting for Medicare eligibility.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.I’m a therapist who has opted out of Medicare. I have a client with BCBS-MA Medex. Can therapy be billed under this plan, and how can I do so without violating Medicare rules?
If you have formally opted out of Medicare, you cannot bill Medicare or any Medicare-covered services to Medicare Advantage or Medigap plans. BCBS-MA Medex is a Medicare Supplement, which means it only pays secondary to Medicare and generally requires the provider to be Medicare-eligible. Since you are opted out, therapy services that Medicare would normally cover are typically not payable by Medex. To stay compliant, you must bill the client as private pay.Are there any exceptions for medical nutrition therapy or therapeutic supplements under Medicare?
Yes — but coverage is limited to specific conditions.Medicare Part B covers Medical Nutrition Therapy (MNT) only for people with:
• Diabetes (Type 1, Type 2, or gestational)
• Chronic kidney disease (not on dialysis or on dialysis)
• Kidney transplant within the last 36 months
This benefit includes a nutrition assessment, follow-up visits, and counseling by a registered dietitian or qualified nutrition professional.
Therapeutic supplements (like vitamins or minerals) are not covered under Medicare unless they are part of a medically necessary, doctor-prescribed enteral or parenteral nutrition (for example, tube feeding or intravenous nutrition).
How does Medicare cover COPD treatment and oxygen therapy?
Answer from Janix Barbosa-Llanos, MBA, PMP, CEP, RSSA, FSN(Licensed Insurance Agent — For Educational Purposes Only)
COPD treatments are usually paid for by Medicare through various parts of Medicare, depending on the type of services provided.
Under Medicare Part B, patients with COPD could get help paying for visits to physicians, pulmonary rehabilitation, breathing studies, nebulizers, durable medical equipment, including oxygen equipment, and medically necessary oxygen therapy prescribed by a physician. Durable medical equipment includes oxygen concentrators and portable oxygen systems, which are covered under Medicare Part B after Medicare requirements are met.
Medicare Part D or a Medicare Advantage plan with prescription drug coverage will help cover inhalers and other COPD prescriptions.
Medicare / CMS Disclosure
For educational purposes only. Not affiliated with or endorsed by Medicare or any government agency. Plan availability and benefits vary by ZIP code and individual eligibility.
Can I use my Medicare when I travel to another state?
Yes. If you travel to another state within the U.S., Original Medicare covers you anywhere in all 50 states and U.S. territories, as long as the provider accepts Medicare. If you have a Medicare Advantage plan, emergency and urgent care are covered anywhere in the U.S., but routine care may be limited to your plan’s service area.
What's the difference between Medicare and Medicaid?
One of the most common questions I hear is:“What’s the difference between Medicare and Medicaid?”
While the names sound similar, they are actually two very different programs.
Medicare is primarily health insurance for:
• People age 65 and older
• Certain younger individuals with disabilities
• People with End-Stage Renal Disease (ESRD) or specific qualifying conditions
Medicare is generally based on age or disability status — not income.
Medicaid, on the other hand, is a needs-based program designed to help individuals and families with limited income and resources. Medicaid rules can vary from state to state.
Here’s a simple way to think about it:
• Medicare = Age or disability-based health coverage
• Medicaid = Income and asset-based assistance program
Some people qualify for BOTH Medicare and Medicaid at the same time. These individuals are often referred to as “dual eligible” beneficiaries.
When someone qualifies for both programs, Medicaid may help pay for things like:
• Medicare premiums
• Copays and deductibles
• Additional healthcare services
• Long-term care support in some situations
This is why proper guidance matters so much. Many seniors don’t realize they may qualify for additional assistance programs that could potentially save them thousands of dollars each year.
I spend a lot of time helping seniors and families understand these programs, review their options, and connect them with resources that may help — always at no cost.
Chuck Winslow
US Marine Veteran 🇺🇸
Retirement & Legacy Planner
Contact me.
If I don't have a primary physician will my new carrier assign me to one?
Yes — in many cases, if you enroll into certain Medicare plans, especially HMO plans, the insurance carrier may automatically assign you a Primary Care Physician (PCP) if you do not select one during enrollment.However, you usually still have the ability to change your assigned doctor afterward if you would prefer someone else who is in-network and accepting new patients. I always recommend reviewing the provider network carefully to make sure the doctor, specialists, hospitals, and medical groups are a good fit for your healthcare needs and location.
I also partner with senior-focused healthcare networks and medical groups that offer strong support for Medicare beneficiaries, including access to quality primary care physicians, quicker new-patient appointments, coordinated specialist care, wellness resources, and senior activities. My goal is not only to help clients select a plan, but also help connect them with healthcare resources and support systems that can improve their overall experience and quality of care.
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.What is the cost and value of a supplemental plan, and what plans are available?
This is a big question with a LOT of variables.First, there are two pathways for supplemental medicare coverage: a medigap plan, or a medicare advantage plan. Which option is right for you depends on a lot of factors. But in general:
Cost:
Medigap plans will always have a premium tied to them. What the premium is depends on several factors and on the plan you choose. A high deductible plan G will have a much lower premium than a standard plan G, for example.
Medicare advantage plans are USUALLY (but not always) premium free so there could be no additional cost beyond your part B Premium.
In both cases you must continue to pay your part B premium in addition to any plan premiums to remain eligible.
Value:
The value of a Medigap plan is flexibility. There are no networks, so if a doctor accepts medicare, they accept your medigap plan. What your copayments or coinsurance would be depends on the plan you select. For example, if you choose a standard plan G, you pay the Medicare Part B deductible ($283 in 2026) and the plan pays the rest of your medical expenses. The coverage is simple. You do need to pick up a standalone Medicare Part D plan for prescription drug coverage, and there is no preventive dental, vision or hearing coverage.
A medicare advantage plan will typically include your part D coverage, as well as basic dental, hearing and vision coverage. Often you will get some comprehensive dental, a copay or stipend for hearing aids, and a stipend for eyewear. You will have a medical network (an HMO or PPO) which means you have to work with doctors in that network, and while there’s typically no premium, you will have copays for most services and those will vary by carrier and by plan within a carrier.
What plans are available?
This is going to depend on your location. Most areas have the same medigap plans available, but medicare advantage options differ by county. So, you would need to talk to an agent or go to medicare.gov to see all your options.
Which cancer screenings are free under Medicare?
I’m glad you asked. Medicare does cover many cancer screenings at no cost to you.When we say “free,” it usually means you pay nothing as long as the doctor accepts Medicare. Medicare says most preventive screenings are covered this way.
Some common cancer screenings Medicare may cover at no cost are:
Breast cancer screening
Medicare covers a screening mammogram once every 12 months for women age 40 and older.
Cervical and vaginal cancer screening
Medicare covers Pap tests, HPV tests, pelvic exams, and breast exams. Most people can get these once every 24 months. Some higher-risk people can get them once every 12 months.
Colon cancer screening
Medicare covers several colon cancer tests. This may include a colonoscopy, stool test, blood-based test, CT colonography, or at-home stool DNA test if you qualify. Many of these are no cost if the doctor accepts Medicare.
Lung cancer screening
Medicare may cover a yearly lung cancer scan if you are age 50 to 77, have a smoking history, and meet the Medicare rules.
Prostate cancer screening
Medicare covers the PSA blood test once every 12 months for men over 50. The PSA blood test is no cost, but the doctor’s prostate exam may have a cost.
One thing to know: if the test turns into something more than a screening, there may be a cost. For example, if a doctor finds and removes a polyp during a colonoscopy, Medicare may charge part of the cost.
The best thing to do is ask the doctor’s office before the test!
Does Medicare offer life insurance, or is that a separate product I need to buy?
Life insurance is a separate product not covered by Medicare... Medicare is health insurance not life. Medicare will cover hospice care, which is an end-of-life benefit: nursing care, pain management, medical equipment, but not a cash death benefit like life insurance.Social security does have a one-time $255 death benefit, but best to connect with them for the details... It's not through Medicare.
Does Medicare ever call you at home, or is every call a scam?
Generally speaking, Medicare will never call you unprompted. They will only call if you explicitly requested a callback or if you recently reported fraud. If you receive an unexpected call from someone claiming to be from Medicare, simply hang up and call Medicare directly at 1-800-MEDICARE to verify. Scammers can easily fake caller ID numbers, so even if the incoming call appears to be official, ignore it and manually dial the number yourself.
Does everyone pay the same for Medicare?
No. While most people pay the standard Medicare Part B premium, higher-income beneficiaries may pay more due to the Income-Related Monthly Adjustment Amount (IRMAA). IRMAA is based on your income from two years prior and can increase the cost of Part B and Part D coverage.In addition, Medicare Advantage, Part D, and Medicare Supplement plan premiums vary by plan, carrier, age, location, and other factors. As a result, two people with Medicare may pay very different amounts for their overall coverage.
Do I need to notify Medicare or Social Security if I move to a new address?
Yes, you will want to notify both Medicare and Social Security when you move. This not only helps ensure you continue receiving important communications regarding your Medicare coverage, premiums, Social Security benefits, and annual plan information, but it may also qualify you for a Special Enrollment Period (SEP) if you need to change your Medicare plan based on your new location.In many cases, updating your address with Social Security will also update your Medicare records automatically.
You can update your address:
✔️ Online through your SSA.gov account
✔️ By calling Social Security
✔️ Or by visiting your local Social Security office
If you are moving, it’s always a good idea to contact a local Medicare broker who can help you review whether your current plan still fits your needs in your new area.
If you have questions, I’m always happy to help!
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.
How do Medicare copays work?
With Medicare, a copay—like any copay—is a fixed amount you pay for a covered service, such as a doctor visit or prescription.Original Medicare Part B typically doesn’t have copays. Instead, after you meet your deductible, you generally pay 20% coinsurance while Medicare pays 80%.
Medicare Advantage plans often replace that percentage with predictable copays, such as $0 for a primary care visit or $40 for a specialist.
Each plan has its own copay schedule.
Knowing your copays ahead of time helps you avoid surprises.
My parents, ages 90 and 91, can no longer afford their Medicare Supplement Plan F and do not qualify for Medicaid. What happens if they cannot pay the 20% not covered by Medicare after cancelling the supplement?
Since they do not qualify for Medicaid, dropping all supplemental coverage is highly dangerous. Instead, the best path forward is looking into Medicare Advantage.Many Medicare Advantage plans have $0 monthly premiums. Your parents will have to pay copays as they use the plan, but the plans have Maximum Out-of-Pocket (MOOP) limits. Once they hit that limit in a calendar year, the plan covers 100% of their medical costs, giving them the exact financial safety net they need without the heavy monthly premium of a Plan F.
They can enroll during the Annual Enrollment Period with no underwriting.
Beyond costs and benefits, should I consider an insurance company’s reputation, values, or social responsibility when choosing a Medicare plan?
Yes, but I recommend making it a secondary consideration after evaluating the plan’s coverage, provider network, prescription drug coverage, and total out-of-pocket costs.A company’s reputation can provide insight into areas such as customer service, claims handling, member satisfaction, and how responsive they are when issues arise. Some seniors also prefer to support companies whose values align with their own, whether that’s community involvement, environmental initiatives, veteran support, or charitable giving.
However, the “best” Medicare plan is usually the one that best fits your personal healthcare needs. A highly respected company may not necessarily offer the strongest provider network in your area or the lowest costs for your medications.
What role do Social Determinants of Health play in Medicare plan quality?
Original Medicare Part A & B focus on helping pay your hospital and doctor bills; however, Medicare plans that fall under Part C of Medicare, also known as Medicare Advantage plans, go far beyond just helping pay your healthcare costs. They can play a key role in helping their members access assistance programs that are in place to address issues around social determinants of health.Social determinants of health are the non-medical factors—such as financial health, nutrition, housing, and transportation—that impact individuals’ health outcomes. Unmet social needs can exacerbate health conditions, prevent people from accessing needed health care in timely fashion, and increase reliance on more costly hospital and emergency services.
Helping Medicare beneficiaries address social needs by connecting them to government and community-based programs that provide services like financial support, meal delivery, housing assistance, and ride sharing can improve health outcomes, enrollees’ quality of life, and support effective use of the health care system. Health plans and providers, community-based social service organizations, and government agencies each have a role to play in
addressing social determinants of health.
Medicare Advantage (MA), which covers about half of all Medicare beneficiaries, is well-positioned to play a leadership role. Unlike Medicare fee-for-service, the integrated MA model can wrap a wholistic medical and social support model around Medicare enrollees.
What is creditable coverage and why does it matter for Medicare?
Creditable coverage means your health plan or drug plan meets Medicare minimum coverages. Another way to say this is that your existing coverage such as an employer plan will pay and cover at least as much as what a Medicare plan would pay and cover. It’s very important because if you do not have creditable coverage, you could be subject to late enrollment penalties. The Good News is that if you like your employer health insurance and it IS considered creditable, you can stay on the plan – without a penalty. CAUTION: when you decide to retire, there are timelines to move from the employer plan to Medicare. Be sure to understand enrollment timelines to transition smoothly without any penalties.
Do you need a scope of appointment to discuss Medicare Supplement plans?
If we're discussing original Medicare, such as supplements to Medicare (Plan G, Plan N etc.) then no. These plans are not regulated by the federal government. We are free to discuss pricing, carrier comparisons and underwriting. These are regulated more at the state level.A scope of appointment is required if we're discussing Medicare Advantage (Part C) or prescription plans (Part D). These are federally regulated by the Centers for Medicare & Medicaid Services (CMS), which mandates documenting the scope of the conversation before the appointment.
Can a drug plan drop one of my medications during the middle of the year?
Yes, Medicare prescription drug plans ( Part D) can remove drugs from their formulary or changed their coverage rules through out the year. The plan can drop a medication or move it to a higher, more expensive tier. They must provide the consumer a 30 day notice. Plans may also add restrictions like prior authorization or quantity limited.There are protected drug classes that drug plans must cover medications, Those six protected classes are immunosuppressants, antidepressants, antipsychotics, anticancer, anticonvulsants and HIV/Aids treatments.
If a plan stops covering your medication, you can appeal the decision or request an exception through your plan's formal process.
I’m 67, working full time, and previously had a 4-month job gap. I enrolled in Medicare A and B to avoid penalties, but SSA won’t let me disenroll from A. I haven’t claimed Social Security and don’t need Part A, which blocks my HSA. What can I do?
First, I recommend confirming with your employer’s HR department that your current coverage is creditable and that you are not required to enroll in Medicare Part A yet. You’ll also want to make sure your plan is a qualifying High Deductible Health Plan so you can continue contributing to your HSA.Take time to weigh the pros and cons. Once you drop Part A, getting back on can be a bit of a process, so make sure delaying it is truly the right move for you.
If you decide to delay Part A, you’ll need to complete form CMS‑1763. This form must be handled through a Social Security representative.
What if you have Medicare and SSI or you have both Medicare and Medicaid how do you qualify for LIS or Extra Help?
If you have Medicaid, SSI, or a Medicare Savings Program, you typically qualify automatically for Extra Help (Low-Income Subsidy) with your Medicare Part D drug costs. This means your premiums, deductibles, and copays for prescriptions are significantly reduced. You usually do not need to apply separately because the benefit is assigned automatically through the Social Security Administration. If someone does not automatically qualify, they can apply directly through Social Security based on income and asset limits. Extra Help can substantially lower prescription drug costs for eligible Medicare beneficiaries.
If I already have part A and am already terminal on hospice care, do I need to get on part B and go through the MAPD/MedSup enrollment process?
Medicare Part A covers 100% hospice related services. Some of these services include nursing care, medical equipment (such as oxygen, hospital beds and wheelchairs), hospice aide services, counseling, and respite care.The only exceptions that are not covered by Medicare are co-pays for prescription medication dealing with pain management. These co-pays are limited to a $5 charge. If respite care is used, there is a 5% co-insurance.
Respite care is where relief is provided for primary caregivers. This allows a break for caregivers while making sure their person is still safe. Respite care is covered up to 5 days at a time.
Whether or not you should get on Part B depends on your prognosis from your doctor. Hospice care is designed to support individuals with a life expectancy of six months or less if their illness follows its natural course. Hospice can be extended as long as the patien continues to meet eligibility standards. Recently, former President Carter was in hospice for 22 months before he passed away in December 2024.
Overall statics show the median length of hospice care in the US is 18 days. 50% of patients pass away in the first three weeks. Up to 15% of patients survive longer than 6 months. With those statistics in mind, I would suggest to someone that they go through the Part B process only if they have a complete understanding of their remaining life expectancy from their doctor.
Some people will stay enrolled in Part B and Advantage or Supplement Plans if they need medical care or prescriptions unrelated to the hospice diagnosis. Obviously you want to have coverage if you have needs for non-medical care or prescriptions. Conversely, I suspect someone on hospice is not going to have a need to see an orthopedic surgeon. My best advice is use common sense based on your current condition.
Does Medicare have a deductible?
Yes Medicare has deductibles for both Part A and B. Part A i(Hospital) is not a standard yearly deductible, but a deductible for a benefit period of $1,736 if you have an inpatient hospital stay. A benefit period begins when you are admitted to a hospital and ends when you haven't received inpatient care for 60 days in a row. You can have multiple benefit periods in a single year. If you have multiple benefit periods, your Part A deductible will reset.Part B (Medical) has a standard yearly deductible of $283. Once the deductible has been met, Medicare pays 80% and you pay 20%. If you add an Advantage Plan, deductibles wil vary by plan. If you add a Prescription Drug Plan, deductibles will vary but are capped at $615 per year by the government.
Part A has no premium, Part B has a premium of $202.90. If you decide to add other sevices, like a Supplement Plan and a Prescription Drug Plan (Part D) you will still need to pay your Part B premium and whatever premium you have for a supplement or drug plan.
Can Medicare drop your coverage or cancel your plan?
Yes — but it depends on what type of Medicare coverage you have.Original Medicare itself generally does not “cancel” you as long as you continue paying any required premiums, such as your Part B premium. However, Medicare Advantage and Part D prescription drug plans can end or change coverage under certain situations.
Some common reasons coverage could be affected include:
• Not paying your monthly premiums
• Moving outside your plan’s service area
• Giving incorrect information on an application
• Losing Medicaid or Extra Help status if your plan depends on it
• A plan leaving the market or discontinuing coverage in your county
• Medicare terminating its contract with a carrier
Every year, insurance companies can also change:
• Provider networks
• Prescription drug formularies
• Copays and deductibles
• Extra benefits
• Plan availability
That’s why reviewing your Medicare coverage annually is extremely important — even if you’ve had the same plan for years.
I’ve met many seniors who assumed everything stayed the same, only to later discover their doctor was no longer in network, medications changed tiers, or benefits were reduced.
The good news is that in many situations, if a plan ends or coverage changes, you may qualify for a Special Enrollment Period to choose new coverage.
This is exactly why I spend so much time educating seniors and families so they understand how Medicare actually works and what protections they may have available.
If you ever have questions about your plan or want a second set of eyes on your coverage, I’m always happy to help at no cost.
Chuck Winslow
US Marine Veteran 🇺🇸
Retirement & Legacy Planner
Contact me.
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 long should I keep my Medicare Summary Notices?
A good rule of thumb is to keep your Medicare Summary Notices for at least one year, longer if a bill, claim, appeal, or tax question is still unresolved.Your Medicare Summary Notice, often called an MSN, is not a bill. It is a record of Medicare Part A and Part B claims, including services or supplies billed to Medicare, what Medicare paid, and the maximum amount you may owe.
These notices can help you check for billing errors, compare them with provider bills, and review claim decisions.
You may want to keep them longer if:
• You are disputing a claim
• You are appealing a denial
• You need them for tax records
• You have ongoing medical treatment
• The notice relates to a bill that has not been fully resolved
If everything matches your bills and there are no open questions, many people keep Medicare Summary Notices for about a year and then safely shred the paper copies.
You can also view Medicare claims online through your Medicare.gov account, which may reduce the amount of paper you need to keep.
How do I request a doctor be added to my Medicare Advantage plan?
You cannot directly “add” a doctor to a Medicare Advantage plan yourself, since provider participation is based on contracts between the doctor and the insurance company. However, you can ask your doctor’s office if they are willing to contract with the plan, and you can also contact the plan to request they reach out to that provider. Keep in mind that network changes are not guaranteed and can take time. If keeping a specific doctor is critical, you may need to consider a plan that already includes them in-network.CMS says Medicare payments are safe for now with the government shut down and providers should issue ABNs for expired telehealth services, expecting a congressional fix — but if the shutdown lasts and Congress doesn’t act, what ripple effects could eventually hit providers or beneficiaries?
If the government shutdown continues and Congress doesn’t act, Medicare payments remain safe short-term, but ripple effects could follow:Telehealth gaps: Expired waivers mean some virtual visits may go unpaid unless Congress restores authority.
Payment delays: Claims tied to affected services could be held or slowed.
Reduced oversight: CMS surveys, certifications, and new program approvals may pause.
Provider strain: Smaller practices could face cash-flow issues.
Access issues: Seniors may lose some telehealth or home-based options.
If prolonged, the shutdown could create disruptions in access, reimbursement, and provider stability until funding and policy authority are restored.
Can I have both Medicare and Medicaid at the same time?
Yes. You can have both Medicare and Medicaid at the same time. Individuals who qualify for both are called dual-eligible beneficiaries.* Medicare is your primary health insurance.
* Medicaid helps pay Medicare costs, such as premiums, deductibles, copays, and coinsurance, and may also cover services like dental, vision, hearing, transportation, and long-term care.
Many dual-eligible individuals enroll in a Dual Eligible Special Needs Plan (D-SNP), which combines Medicare benefits with extra services such as prescription drug coverage, dental, vision, hearing, OTC allowances, transportation, care coordination, and, on some plans, grocery or utility benefits.
To qualify, you must:
1. Be eligible for Medicare, and
2. Meet your state’s Medicaid income and eligibility requirements.
Medicaid assistance may include Full Medicaid or a Medicare Savings Program (QMB, SLMB, QI, or QDWI), depending on your eligibility.
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.
Is there a Medicare office near me where I can get help in person?
There are no dedicated Medicare offices. You can resigster for Medicare at your local Social Security office of online at www.ssa.gov. You can alo contact your local office of the State Health Insurance Program (SHIBA) which provides free counseling and will help you understand the complexity of Medicare rules and processes.Medicare also offers support through a toll-free numbner at 1-800-MEDICARE or use their live chat feature. This office will be able to assist you with general questions, penalties, checking eligibility, or submitting a complaint.
You can also use a local, indepoendent Medicare broker. Many brokers will offer an educational seminar introducing Medicare to people ready to enroll. Brokers work with multiple insurance carriers and should be able to suggest plans based on your needs.
I was denied guaranteed issue coverage because my prior insurer no longer exists and was never informed. Does coverage have to be retroactive to January 1?
Short answer: No—guaranteed issue (GI) coverage does not automatically have to be retroactive to January 1.But there are important timing rules, and your denial may still be incorrect depending on what happened.
Let’s break this down clearly 👇
⸻
1. How Guaranteed Issue actually works
You get Guaranteed Issue rights to buy a Medigap plan without medical underwriting when you lose certain coverage through no fault of your own—including when:
• Your prior insurer goes out of business
• Your plan terminates or is discontinued
• You were never properly notified of the loss of coverage
That sounds like it may apply to your situation.
⸻
2. Does the Medigap policy have to start January 1?
No. Medigap GI policies:
• Start based on when you apply
• Or the month your prior coverage ended
• Or the month after you lost coverage, depending on the scenario
There is no Medicare rule that says GI Medigap coverage must be retroactive to January 1 unless:
• You applied for it to start then and
• You were eligible at that time
Most carriers do not backdate Medigap policies unless there is a clear administrative error and documentation.
⸻
3. The critical issue: the 63-day window
This is where many denials happen.
You generally must apply for GI Medigap:
• Within 63 days of losing your prior coverage
If:
• You were never informed your prior insurer no longer existed, or
• You reasonably believed you still had coverage,
then that 63-day clock may not have started yet—and the carrier may be wrong to deny you.
⸻
4. Why the denial may be improper
A denial can be challenged if:
• The insurer cannot prove you were notified
• Your prior coverage ended without your knowledge
• You applied promptly once you became aware of the loss
In those cases, carriers often must:
• Reprocess the application under GI rules, or
• Accept coverage effective the month of application
⸻
Does IRMAA reset every year, or does it stay the same once you're assessed?
IRMAA is reviewed every year, so it does not stay locked in once it has been assessed.Social Security usually looks at your tax return from two years earlier. For example, your 2026 IRMAA is generally based on your 2024 income, and your 2027 IRMAA will generally be based on your 2025 income.
That means the surcharge can go up, go down, stay the same, or disappear altogether depending on your income.
The important part is that IRMAA is not a lifetime penalty. If your income drops because you retired, reduced your work hours, lost a spouse, divorced, or experienced another qualifying life change, you may be able to ask Social Security to recalculate it instead of waiting for the normal two-year lookback to catch up.
That is why I tell clients not to look at IRMAA as a one-time Medicare decision. It needs to be reviewed each year as part of the bigger retirement income and healthcare strategy.
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.
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.
I'm over 65, not enrolled in Part A or B, and leaving active coverage through an employer with 20+ employees for six months of COBRA.
No, once your active employer coverage ends, your 8-month Special Enrollment Period starts immediately, and COBRA doesn't extend or pause it. So even if you elect 6 months of COBRA, you still need to enroll in Part A and B within 8 months of your active coverage ending, not 8 months from when COBRA runs out. Waiting until COBRA ends would put you outside the SEP window and risk a late enrollment penalty plus a potential gap in coverage.
Do you lose Medicare if you move out of the country?
No. What happens when you move out depends which parts of Medicare you have and whether you expect to return to the USA.You can generally keep your Medicare part an even if you live abroad. Understand that original Medicare generally does not pay for healthcare received outside the United States. You can generally keep your Medicare part A even if you live abroad. Understand that original Medicare generally does not pay for healthcare received outside the United States with a very few narrow exceptions.
Part B. You may keep part B, even though you cannot use it abroad. If you later return and you already have part B and drop it you may have to wait for an enrollment period to re-enroll and could owe a late enrollment penalty unless you qualify for a special enrollment.
Part D if you leave the service area, which, if you’re living outside the USA, your plan will generally disenroll you because you no longer reside in the Service area. If you later return, you will usually qualify for a special enrollment. To enroll in a new part D plan.
Part C same answer as above for parts C
Can I have Marketplace and Medicare coverage at the same time
No. Once you are enrolled in Medicare Part A or Part B, you are not eligible for premium tax credits (subsidies) on a Marketplace plan. It is against the law for an agent or insurer to knowingly sell you a new Marketplace plan if you have Medicare. You can technically keep an existing Marketplace plan after enrolling in Medicare, but:*You will pay the full premium (no subsidies).
*The insurer may not renew the plan at the end of the year.
*It is almost always a waste of money because Medicare duplicates much of the coverage.
Rare Exceptions:
*If you pay premiums for Part A (not premium-free) and choose not to enroll in Medicare, you may keep subsidized Marketplace coverage.
*ESRD (End-Stage Renal Disease): Limited flexibility to keep or enroll in Marketplace with subsidies in some cases.
How do I find out if Medicare covers a specific procedure before I have it done?
You have a several options to learn if a specific procedure is covered by original Medicare and if there will be any co pays , coinsurance, and /or deductible requirements triggered with having the procedure done.1- Contact your Local, Licensed, Medicare Agent- They can quickly answer your question.
2- Visit www.Medicare.gov and look up covered procedures.
3- If you downloaded the Medicare App, What's Covered, you can look up the procedure on the app.
4- Call Medicare Directly at 800-Medicare
5- Ask the Provider's Office/Ordering Provider if the procedure will be covered
* Some procedures may be covered as part of the preventative/screening benefits as part of your Medicare benefits. Things like a mammogram, colonoscopy, etc...There are limitations and frequency requirements with included preventative and screening benefits.
* * Keep in mind, depending on where you have the procedure (inpatient / at the hospital) vs outpatient (freestanding Ambulatory Care Center/ Surgery Center) may have different cost shares. Also, there are typically costs associated with the procedure/services, and then there are professional fees (provider fees).
What is the difference between Plan G and Plan N of Medicare?
There are a couple of difference between these two plans. First Plan G is the more comprehensive plan and typically more expensive. Plan G has very minimal out of pocket , you simply pay your monthly premium and the Medicare part B deductible and than you will be 100% covered for all Part A&B covered services.Plan N still a good plan covers 100% of Part A deductible and you still have to pay the Part B deductible each year and once you do Plan N allows a maximum of $20 at a doctors office & a $50 copay at the emergency room. Lastly Plan N does not cover provider excess charges. This means if a doctor has not opted into Medicare's rates meaning they do not accept Medicare's usual an customary for payment they can bill up to 15% on top. Currently less than 5% of all doctors have opted out nationwide.
Is IRMAA recalculated every year?
The Social Security Administration reviews your income annually They usually base it on your tax return from two years prior Example: your 2026 IRMAA is typically based on your 2024 income.Your IRMAA can go up, down, or disappear each year depending on your income. If your income drops, your IRMAA may be reduced the following year automatically.
If your income drops significantly due to certain events, you don’t have to wait a full year. You can request a reassessment using SSA-44 for situations like:
Retirement or reduced work hours
Divorce or death of a spouse
Loss of income-producing property
Pension loss
What is the difference between secondary insurance and supplemental insurance for Medicare?
“Supplemental insurance” usually refers specifically to Medigap, which is designed to work with Original Medicare and pay deductibles, coinsurance, and gaps. It follows standardized benefits and only works with Original Medicare.“Secondary insurance” is a broader term — it means any coverage that pays after Medicare, including Medigap, Medicaid, employer retiree plans, or other coverage.
So, all Medigap plans are secondary insurance, but not all secondary insurance is Medigap.
If I leave the hospital against medical advice, will Medicare still pay the bill?
Yes, Medicare will still pay for covered services even if you leave the hospital against medical advice (AMA). As long as the care you received was medically necessary and Medicare-approved, your coverage is not denied simply because you left early.However, you may still be responsible for deductibles, coinsurance, and any services not covered, just like any other hospital stay. It’s always a good idea to speak with hospital staff before leaving to understand any potential risks or costs.
Why is it important to find an agent with great reviews from long time existing clients.
Reviews from clients give you an idea of how that agent works. Do they respond in a timely manner? Are they helpful in finding solutions? Will they just sell you a plan and then you never hear from them again?A great agent truly cares about their clients. They care about not only your experience, but your health as well. I understand that your health will change from year to year and your budget may change as well. That is why having an agent who responds to you is so invaluable.
If you enroll through the company and you run into problems, you will spend a lot of time on the phone, telling your story over and over to multiple people before you reach the right department.
Having an agent means you have a real, live person to call to receive help. No repeating yourself over and over, just real help from someone who knows you personally and cares about you.
Is home healthcare becoming the preferred option for Indian seniors? Why?
Yes — home healthcare is increasingly becoming a preferred option for many Indian seniors, and there are several reasons behind this trend. India’s elderly population is growing rapidly and many seniors have chronic conditions that require ongoing care, making home-based services a practical alternative to frequent hospital visits. The shift away from traditional joint families and migration of younger relatives for work means many seniors now live alone, so families increasingly choose personalized care at home for comfort, safety, and dignity. Post-COVID concerns about hospital exposure, rising healthcare costs, and tech-enabled care options like telemedicine and remote monitoring have also made home healthcare more attractive and accessible.How can I find out if Medicare will cover a specific procedure or treatment?
To find out if Medicare will cover a specific procedure or treatment:• If you have Original Medicare – use the coverage tool on Medicare.gov to check.
• If you have a Medicare Advantage plan – check your plan’s benefits list, or call the plan’s member services number.
Can I see a doctor in another state with Medicare?
If you have original Medicare and the doctor accepts Medicare in another state, yes!Also, it will hold true if you have a Medicare Supplement or Medigap Plan. Where original Medicare leaves off, the Medicare Supplement or Medigap Plan would work according to the plan you select. Medicare Supplement Plans or Medigap plans are not tied to any network. You can see any medical professional or any medical facility as long as they take Medicare.
However, if you have a Medicare Advantage plan, then you need to be careful and make sure that you know what your plan offers and identify if the doctor is in the network. If it is an emergency situation, your Medicare Advantage plan will typically cover you. Beyond emergencies, the PPO Medicare Advantage plans will typically offer in network and out of network coverage. If you see a doctor out of state, it will likely mean that it will be out of network and your costs will likely be higher. It is important to note that as of 2025 and 2026, more and more insurance carriers are pulling out of the Medicare Advantage PPO market, and the trend will likely continue into 2027. The PPO plans are not expected to come back any time soon within the industry. With HMO plans, you will not likely be able to see a doctor in another state as they would not likely be considered in network. Networks typically run in regional geographic areas.
As with any situation, you will want to make sure the doctor out of state is willing to see new patients.
Are new Medicare cards being issued for 2026?
Red, white, and blue Medicare cards are typically sent out when you first go on Medicare, and you would also typically receive a new Medicare card once you pick up Part B Medicare. Some people work beyond the age of 65 and are covered under their employer's coverage and it would likely be considered creditable coverage. If a Medicare Beneficiary picks up Part B Medical later, then a new card would be issued.Outside of this timeframe, people do not usually receive a new Medicare card except in special circumstances. From time to time, it might be identified that a Medicare Beneficiary Identification number was compromised. If this is the case, then a Medicare beneficiary would likely receive a new Medicare card along with a letter explaining why a new Medicare card was issued.
If you need a Medicare card or new Medicare card, there are multiple options to obtain one. The fastest way is online through MyMedicare.gov. You are able to see and print a copy of your Medicare card. You can request it on your Social Security account and select the option to "Replace my Medicare Card." Social Security is the gatekeeper to Medicare. You can reach them via phone, but they do have limited hours. The phone number is: 1-800-772-1213 (TTY: 1-800-325-0778), Monday through Friday, 7 a.m.–7 p.m. You can also call Medicare at 1-800-MEDICARE and request a replacement card be mailed to you. Medicare is open around the clock and on the weekends.
I have Medicare through Mutual of Omaha but I have no Medicare cards. How do I get my part A and B cards.
Your Medicare card (Parts A & B) comes from the federal government, not from Mutual of Omaha. What you have through Mutual of Omaha is likely a Medicare Supplement (Medigap) plan, which is separate from your actual Medicare coverage.Here's how to get your red, white, and blue Medicare card:
Online (fastest):
- Go to mymedicare.gov
- Create or log into your account
- Request a replacement card directly through the portal
By Phone:
-Call 1-800-MEDICARE
In Person:
- Visit your local Social Security Administration office
- Bring a valid photo ID
Things to know:
- Replacement cards are free
- It typically arrives within 30 days
Are there churches or community organizations in my area that help with Medicare questions?
Yes, in PA there are 3 main sources and organizations that offer free and unbiased Medicare counseling. These are, You Local Area Agency on Aging, PA MEDI Helpline, and Senior Community Centers. These places have counselors that are specially trained to assist with plan comparisons, enrollments and appeals.
I'm hesitant to share personal or financial information with an insurance agent. Is my information safe with you?
Insurance agents are required to follow privacy laws and protect your personal information. Only necessary information such as your ZIP code, age, preferred doctors, prescriptions, and Medicare eligibility date are needed to compare plans. Financial information should only be shared if you are choosing to enroll in a plan and that insurer requires the information. Don't hesitate to ask why a piece of information is needed, how it will be used, and who will have access to it.Are there Medicare plans that also help with chronic conditions like diabetes or high blood pressure that run in my family?
Yes. Many Medicare Advantage plans offer care management programs for chronic conditions such as diabetes, heart disease, and high blood pressure. If you already have certain qualifying conditions, you may also be eligible for a Chronic Condition Special Needs Plan (C-SNP), which provides more specialized care coordination and benefits.If these conditions only run in your family and you haven't been diagnosed, you won't qualify for a C-SNP based on family history alone. However, Medicare covers preventive services like diabetes screenings for people at increased risk, and many Medicare Advantage plans offer wellness programs to help you stay healthy.
I take care of my elderly parent. Can I get paid as their caregiver?
If you're taking care of an aging parent or spouse at home, I want to tell you about something most people don't know exists — and no, it's not Medicare.
Many states have a Medicaid program that pays an eligible family caregiver a tax-free monthly stipend to care for a loved one at home, instead of that person moving into a nursing facility. It goes by different names depending on where you live — sometimes it's called Adult Foster Care, sometimes Structured Family Caregiving, sometimes something else entirely — but the idea is the same: if you're already providing this care, you may be able to get paid for it.
Generally, your loved one needs to be enrolled in Medicaid and need hands-on help with daily activities. A spouse usually can't be the paid caregiver, but adult children, siblings, and other relatives or close friends often can.
Because the specific program, the payment amount, and the rules are different in every state, the best next step is to call me or your Medicare Agent to find out exactly what's available where you live.
My income is limited. Are there programs that can help pay my Medicare premiums?
Yes, depending on your income and assets, you may qualify for programs that help pay Medicare costs. These include Medicare Savings Programs (MSPs), which can help pay your Part B premium and, in some cases, deductibles, coinsurance, and copayments. You may also qualify for Extra Help (Low-Income Subsidy), which helps lower the cost of Medicare Part D prescription drug coverage. If you qualify for Medicaid, you may also be eligible for a Dual Eligible Special Needs Plan (D-SNP) that provides additional benefits.
Is help available in Spanish when choosing or using my Medicare plan?
Yes — absolutely, and you have a legal right to it. As your broker, I make sure all my clients know about this, whether they need it for themselves or for a family member.Official Medicare - Free, in Spanish
Medicare.gov/es - The entire Medicare website is in Spanish
1-800-MEDICARE - Say "Español" or press 2 for Spanish. They have Spanish-speaking reps 24/7.
Your Medicare & You handbook - Available in Spanish every year
You are allowed to have a family member or interpreter on the call with Medicare, HICAP, or with me. Medicare will just do a quick permission check. I also have access to a free interpreter line, so I can do a three-way call in Spanish if you need me to explain your options to a family member.
What is the donut hole, and does it still exist?
Let's not confuse you with the "Donut Hole" as it no longer exists today. This was part of the Inflation Reduction Act. Medicare Part D - Prescription Drug coverage now operates in 3 phases. 1. Deductible Phase, where you pay 100% of the drug cost until your deductible is met. 2. Initial Coverage Phase, where you typically pay a copay or percentage (%) of the cost, and the plan pays the rest, until out-of-pocket spending reaches an annual cap limit. 3. Catastrophic Coverage Phase, once your out-of-pocket prescription costs reach the annual limit (e.g., $2,100 in 2026), you pay nothing for covered medications for the rest of the year.
Did you know you can receive money back each month from your part B premium?
That benefit is called the Part B Giveback or Part B reimbursement. It will return some of the premium to you monthly for whatever you may need it for. It works somewhat like a discount. As an example, if you enroll in a plan with a $150 giveback benefit, it means each month you will receive $150 of your $202 monthly Part B premium returned to you through your SS checkIn NC, I’m on my husband’s active employer plan with 20+ employees. Since it’s credible coverage, can I delay Medicare, including Part D?
Yes, since your husband's employer plan covers 20+ employees, it counts as creditable coverage for both Medicare and Part D. So you can delay enrolling in Part A, Part B, and Part D without a late enrollment penalty as long as that coverage stays in place. Once the employer coverage ends, you'll get an 8-month Special Enrollment Period to sign up for Part A and B, and a separate 2-month window to enroll in a Part D or Medicare Advantage plan with drug coverage
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.My oxygen provider says I need yearly re-evaluations for oxygen coverage, but my last one lapsed and now they are charging me. I’ve been with them since 2017. Please help.
Medicare does require periodic documentation and recertification for oxygen coverage, especially continued proof that the oxygen remains medically necessary. If the required yearly re-evaluation or physician documentation was missed, the supplier may temporarily stop billing Medicare and charge you directly until updated records are provided.Since you’ve had oxygen since 2017, you may already be beyond Medicare’s standard 36-month rental period, but documentation requirements can still apply for continued service and supplies. Contact your doctor immediately to schedule the re-evaluation and have updated chart notes and oxygen testing sent to the supplier.
You should also ask the supplier for a detailed explanation of the charges and whether they can rebill Medicare once the updated documentation is received.
How does a Medicare insurer's Medical Loss Ratio affect the quality of my coverage?
A Medicare insurer’s Medical Loss Ratio (MLR) is the percentage of premium dollars spent on medical care and quality improvement, rather than administration or profit. Medicare Advantage plans are required by the Centers for Medicare & Medicaid Services to maintain at least an 85% MLR, meaning most of your premium is used for healthcare services.A higher MLR can suggest more spending on care, but it doesn’t automatically mean better quality — efficiency, network strength, and care management also matter.
If a plan fails to meet MLR requirements, it may have to issue rebates or could face penalties, which helps protect consumers.
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