Medicare Questions & Answers: The Medicare System
The Medicare System Q&A
Showing 40 questions
What benefits are there to working with a Medicare Agent near me vs remote/virtual?
As Ohio Medicare Plan, I stick to Ohio’s 88 counties because I believe local agents like me bring far more value with our deep experience in local networks and plan features—details call centers or virtual agents often miss or don’t fully grasp. I’m not licensed outside Ohio, and that’s by design; it lets me stay dialed into what matters most for my clients here. Plus, some clients prefer meeting face-to-face to build trust and get that personal touch, which I’ve seen makes a real difference.
Are Medicare Advantage plans really “free,” or is that just clever marketing?
several carriers offer zero premium plans for medicare advantage plans. they can do this because they get paid by medicare to coordinate your medical care
What role do you think technology will play in the future of Medicare?
Advancements in technology are poised to transform Medicare in the coming years. Telemedicine, which saw explosive growth during the COVID-19 pandemic, is likely to become a permanent fixture in Medicare’s coverage. Other technological innovations, such as artificial intelligence (AI) and wearable devices, have the potential to improve care delivery and outcomes. However, integrating these technologies into Medicare will require addressing challenges such as data privacy, reimbursement policies, and ensuring equitable access for all beneficiaries.
What’s an underrated benefit of Original Medicare that many people overlook?
The most underrated benefit of Original Medicare is freedom of choice. With Original Medicare you can see any provider as long as they take Medicare. no referrals are needed and it travels well. The coverage is Nation wide.What demographic challenges will Medicare face in the coming years?
The aging population also brings a higher prevalence of chronic conditions such as diabetes, heart disease, and Alzheimer’s, which require costly long-term care and management. Medicare must adapt to meet the growing demand for services while ensuring the program remains financially sustainable.Why am I paying more for Medicare Part B and D than my friends? What is IRMAA and how is it calculated?
When clients ask why their Medicare Part B and D premiums exceed others’, I attribute it to IRMAA, the Income-Related Monthly Adjustment Amount, which increases costs based on higher income reported on their tax return from two years prior. Medicare discourages advisors like me from quoting specific thresholds, instead directing individuals to consult the official income brackets and resources to determine their financial responsibility two years hence. The calculation uses modified adjusted gross income, and significant income events—such as a large asset sale—can elevate the surcharge, often unexpectedly impacting their total premium obligation.
What should I do if I miss the Medicare Open Enrollment period, and I want to change my plan?
You may utilize a Special Election Period which includes:Moving to a new plan area.
Enrollment in a 5 star plan.
Losing health insurance.
Weather related disasters.
Annual enrollment. Is October 15th through December 7th. If you miss that enrollment period and you are a current Medicare Advantage member, You have 1 more opportunity to change plans January 1st through March 31st.
So from April 1st through December 31st you are locked into your plan unless you meet a special election period requirement.
If you could change one thing about the Medicare system, what would it be and why?
Medicare is very complex. The cost of prescription drugs are high and it's difficult for some clients to fill their prescriptions due to the cost. It would be great if pricing was adjusted for Medicare clients
What shift has been observed in Medicare spending, particularly regarding Medicare Advantage plans?
Some plans which were in place in 2023 and 2024 have had their Maximum Out Of Pocket (MOOP) increase in 2025.
Are Medicare plans and requirements different for every state?
Plans look different in every state, and in most states, they will differ by counties. There are enrollment rules that may differ between states. You need to reach out to someone who represents multiple companies and plans to ensure you are getting all of the information you need to make an educated decision before enrolling.What’s the deal with Medicare covering medical equipment like wheelchairs—do I need a special approval?
Medicare Part B covers durable medical equipment (DME) like wheelchairs when deemed medically necessary, but you must have a doctor’s prescription and obtain prior approval from Medicare to confirm it meets their criteria, such as being essential for use within your home. This includes items supplied by Medicare-approved DME providers, though many beneficiaries don’t realize this until a need arises, often prompting a last-minute call to advisors for clarification. Without proper approval, coverage won’t apply, and you’d face full costs, so verifying these requirements early is key.How might artificial intelligence change how Medicare approves claims in the future?
AI could transform Medicare claims approval by speeding up the process, spotting patterns, and flagging errors faster than today’s manual reviews—I see it analyzing data in real time to cut delays. My hope is to drive this change to curb fraud, waste, and abuse, boosting efficiencies throughout, which is practical if the tech’s designed to verify claims against solid benchmarks and provider records. With the right system, I’d work to ensure approvals are tighter and taxpayer money goes further.
How will advancements in wearable health tech (like smartwatches) integrate with Medicare?
That is a great question. There a few Medigap carriers who will give you a discount on your premium. I just visited a new client today and she has an Apple Watch and will get a monthly discount. This carrier I just sold gives you a discount if you have an Apple Watch or a Fitbit.
I've heard about IRMAA affecting my Medicare premiums. How can I find out if it applies to me, and how does it work?
IRMAA (Income-Related Monthly Adjustment Amount) affects Medicare Part B and D premiums for those with higher incomes, and it's determined by the Social Security Administration based on your income from two years prior. You'll receive an "Initial Determination" if IRMAA applies to you.
Who can help me figure out this Medicare "maze and alphabet soup" it's so confusing.
Work with someone who can OFFER both Medicare Advantage and Medicare Supplement/Medigap options! Start the process well in advance of your 65 Birthday.Work with a Professional with a Financially Strong/Reputable company. Look up that Professional's Google Reviews that gives you a "spotlight" into how their clients truly feel about them and the Services they provide(d). Take a deep breath-YOU got this!
How can I avoid or reduce IRMAA charges on my Medicare premiums?
The fact is IRMAA charges are calculated based on your AGI (Adjusted Gross Income) from 2 years ago. Know this may give you and your tax accountant time to do some financial planning that will help you pay less IRMAA charges when the time comes. You can do a Google search to see the levels of additional IRMAA charges that will be added to your base Medicare premium.I'm an independent agent and am compensated for my services by the insurance companies. I never charge you additional fees for my services. I'm asked this question (IRMAA charges) quite often by higher income earners. You can contact me at 801-550-1800 to answer questions that will help you better understand what to expect.
Does IRMAA go away automatically if my income drops, or do I need to report it to Social Security?
SSA uses two years of tax returns to determine decrease in income to make a change.
Could Medicare ever adopt a tiered premium system based on lifestyle factors?
This question is a very vague question and difficult to answer without understanding the individual circumstances.Medicare has tiers of cost in their Part B and part D premiums and are based on your income. This does not affect the average Medicare beneficiary unless you’re in those high-income brackets.
Insurance companies operate on different levels, and their cost structure includes high and low deductibles, that can affect your cost.
Why did I receive a Medicare Summary Notice, and what should I do with it?
The notice is used to Notify beneficiaries of decisions on a claim made for Medicare.I would open it and see what claim they are talking about. If you have questions I would call them.
What’s a common Medicare myth that even some agents still believe?
I'd say that some agents still think they have to take additional tests in order to get a non-resident license.
I’ve been paying into Medicare for years, and I’m not sure why my specialist visits still cost me so much. What am I missing here?
That’s a great question, and one we hear a lot. Even though you’ve paid into Medicare through payroll taxes, that mainly covers Part A, which is hospital insurance—not everything. Part B, which covers outpatient care like specialist visits, has its own monthly premium and usually only covers 80% of the cost after you meet the deductible. That means you’re responsible for the remaining 20%, and there’s no out-of-pocket max unless you have additional coverage. This is where a Medicare Advantage or Supplement plan can help reduce or cap those costs. It’s frustrating, but you're not alone—Medicare can feel like a maze, and that's why it's worth reviewing your options to see what might lower your expenses moving forward.How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?
Under traditional Medicare, you will appeal directly to Medicare, and Medicare supplemental/Medigap coverage must follow Medicare's lead in paying your coverage cost. With Medicare Advantage, you will deal directly with the insurance companies that write those plans.Should Medicare cover dental, vision, and hearing, or would that just make it more expensive for everyone?
I believe Medicare should have more dental, vision, hearing, and preventive care services built into the traditional system, just like many Medicare Advantage plans offer these services within their programs.How much is spent on healthcare per year the U.S., and what does this amount represent per person?
The 2023 CMS Healthcare Expenditure Report revealed an eye-opening total of $4.9 trillion spent on healthcare, averaging about $14,570 per person.
How do Medicare Savings Programs help with Medicare costs?
Medicare Savings Programs (MSP) can help people with limited income cover their Medicare premiums, deductibles and other costs like co-insurance. This is also known as a Medicare Buy-In program.Eligibility can be vary by state. Extra help with Medicare Part D drug costs can by applied for simultaneously with the MSP. Income and resources can also vary by state, however most states use income and resource limits based on the Federal Poverty Level (FPL).
Types of MSPs include:
Qualified Medicare Beneficiary (QMB) which helps pay for Part A and B premiums, and covers cost- sharing for Medicare-covered services.
Specified Low-Income Medicare Beneficiary (SLMB) which helps pay for Part B premiums.
Qualified Individual (QI) which helps pay for Part B premiums.
Qualified Disabled Working Individual (QDWI) which helps part Part A premiums for individuals under age 65 who a disabled and have returned to work recently.
You can apply through your State Medical Assistance office (Medicaid).
Every year I stress over picking a plan and still end up surprised by the bills. Is there any way to just get peace of mind with Medicare?
Change from medicare advantage to Medigap. You will pay a monthly premium but never get a bill. You can keep the plan forever and have peace of mind knowing your exact cost upfrontI 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?
If I knew what you have I could understand what you have.If you got a supplemental with a high deductible then you will be paying 20% of your bills until you hit 2700.
If you have a medicare advantage and it is no cost you should not have any surprise billing. It should only be the copay shown. I would have to look at your plan to understand what is happening
I went to a free Medicare seminar and it felt like a timeshare pitch. Are any of those events actually helpful?
Only if you want a free piece of pie. If you want detailed answers on Medicare it's best to talk to a broker that represents a number of different companies. If you have any questions please call me at 239-848-8893.
My husband passed away and now my Medicare premiums went up. Why does losing someone raise your costs?
It is possible you lost a spouse discount if you had a Medicare Supplement plan.
Is Guaranteed Issue available after the Medicare Open Enrollment period ends?
They need to have an SEP Special enrollment after OEP such as moving out of the county their current plan is in.My friend lives in a different city and has a much more detailed Medicare plan. Is their location dependent on their plan?
Yes. You must enroll in a plan available in the service area that matches your legal address. My friends and family members give advice to and mention specific plan benefits. Plan specifics differ across the country. If there is a benefit that you are interested in, please ask. If you don't mention something, your advisor may never know that it was important to you. We ask as many questions as we can to start a conversation, to determine what is most important for each potential client.
How do I report a suspicious Medicare billing error without getting in trouble myself?
Call 1800 Medicare for assistance. Provide them with the information and your questions will be reviewed under compliance.
How could a shrinking workforce affect Medicare funding in the next 20 years?
Medicare is funded through the workforce for future generations which is why its very important that every person working is contributing to this program. We have many workers in the US who are either self-employed or undocumented who are not contributing, that gap needs to be fixed by having a legal path to citizenship for those workers who will also benefit from Medicare when they retire.How might climate change-related health issues (like heat stroke) influence Medicare policies?
In my 25 years working with Medicare, climate change-related health issues like heat stroke have never come up in discussions or policy updates—not once. Honestly, it’s not something I’ve ever thought about either, but I’d assume it wouldn’t shift Medicare coverage much since conditions tied to it are already baked into what’s covered. Any impact would likely stay minor, handled within existing frameworks.Is Medicare becoming more expensive over time, and will it ever be unsustainable?
Medicare costs have certainly risen over time—Part B premiums went from $144.60 in 2020 to $185 in 2025, and I’ve noticed Part D premiums spiking too, largely due to the Inflation Reduction Act shifting some expenses around—though recent crackdowns on waste, fraud, and abuse, like overpayments and non-qualified services, might temper future hikes compared to past jumps. The program’s sustainability gets questioned as more folks age into it, but I’m optimistic that sharper oversight and drug price caps from the IRA could keep things manageable moving forward.
Would expanding Medicare to younger Americans improve or hurt the program?
It could be great in theory, but there’s a risk. If younger people with health issues join the Medicare Supplement pool, it could drive up premiums for everyone. It all depends on how it’s structured and who’s allowed in.Why does Medicare have so many coverage gaps, and is it designed that way on purpose?
When clients ask me this question, I usually answer, "To keep me busy". Seriously, it is an ever changing maze of rules and regulations. Once you think you have everything figure out, the government changes something and throws a curve ball. Working with an independent insurance advisor, allows you to reach out if you have an issue or a question and any point during the year.Should there be stricter regulations on Medicare Advantage marketing and sales practices?
No. The regulations make is harder for honest people and the seniors. The issues is that the dishonest people are NOT following the rules. Calling Seniors with permission to contact forms. They are signing them up without Scope of Appointments.The high pressured scammers are the problem and not following any rules. I get calls every 10 minutes from people trying to pressure me and make false claims about insurance and I am a broker!!
Can you explain how Medicare works with other types of insurance like Veterans Affairs benefits or employer plans?
Veteran Affairs benefits and separate from Medicare. If a Senior is using the VA, Medicare is not responsible for any coverage. If the Senior also has a Medicare plan and sees a doctor outside of the VA they Medicare may pay.In the case where a Senior has an employer plan and Medicare. Typically, the employer plan pays first and then it goes to Medicare as a secondary. But employee plans vary and coverage could work differently.