Medicare Questions & Answers: The Medicare System
The Medicare System Q&A
Showing 73 questions
Are Medicare Advantage plans really "free," or is that just clever marketing?
The concept of "free" Medicare Advantage plans can be misleading. While some Medicare Advantage plans advertise $0 monthly premiums, it's crucial to understand that this doesn't mean you won't have any healthcare costs. Here's a breakdown:* $0 Premium Doesn't Mean $0 Cost:
A $0 premium means you don't pay a monthly fee to the private insurance company offering the Medicare Advantage plan. However, you'll still likely have other out-of-pocket costs, such as:
* Co-payments: Fixed amounts you pay for specific services (e.g., doctor's visits, prescriptions).
* Coinsurance: A percentage of the cost you pay for services.
* Deductibles: The amount you pay before your plan starts covering costs.
Contact at 859-309-5033 if you would help with your Medicare Planning
What benefits are there to working with a Medicare Agent near me vs remote/virtual?
Medicare agents are not supposed to solicit customers without their permission. Therefore, it is essential that you feel comfortable with your agent and trust his knowledge and efforts to provide you with the best plan, for your future, not necessarily for the moment.
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 should I do if I miss the Medicare Open Enrollment period, and I want to change my plan?
If a person misses the Open Enrollment time frame that runs January 1st through March 31, then depending on where the member lives, they may be able to use a disaster SEP to change plans, if they are a veteran, they may be able to use the Veterans SEP; If they move, they can use the Move SEP and finally can call Medicare directly.
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.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.
I live in California but might move to another state next year. How will my Medicare coverage change if I relocate?
Medicare is a federal health insurance program so it will not change but the type of additional coverage such as a Medicare Advantage plan may be affected. If you're enrolled in a Medicare Supplement, only the monthly premium will be affected.
My friend said she got a free annual physical with Medicare, but my doctor billed me. What's going on?
Annual physicals are always free with Medicare. Perhaps your doctor is not in network? Your agent should always check and ascertain that your primary care physician is in network.
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 upfront
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?
The plans are not random. If your friend pays nothing for his Medicare plan, this is highly likely to be a Medicare Advantage plan featuring deductibles, copays and coinsurance depending on the plan. Most advantage plans feature a $ 0-dollar copay to see your primary doctor but will have a $30-to-$ 50 dollar copay to see a specialist and there will be additional costs depending on what's going on. Now if you are paying over $ 200 for your plan, you may have a very high-benefit Advantage plan but it is more likely that you have a Medicare supplement plan and this is a different animal. Medicare supplement plan F pays after Medicare leaving you with no medical bills for health services for Medicare-approved services (or no bills after a 2025 $ 256 outpatient deductible if you have a supplement Plan G). Talk to your independent insurance agent about all this otherwise get your license and help me explain this stuff!
Isn't it concerning that Medicare Advantage plans are taking over the system?
Medicare changed very little in it's first forty years and that is a bad sign in any program or product. Demand for better service and a better product drives competition between the companies that provide Medicare Advantage plans. This competition makes for a better product for all Medicare recipients that are part of the Medicare Advantage program.
I went to a free Medicare seminar and it felt like a timeshare pitch. Are any of those events actually helpful?
Seminars can be helpful - up to a point. But one of the problems is that because Medicare has many different parts and options, a person is best served with a one-on-one consultation.
I tried calling Medicare and got transferred five times. Is there any way to get straight answers from them?
It's much better using a chat on Medicare.gov! Get on the site and set up an account and then get on the Chat feature! I use it regularly and there is almost Immediate help and answers for all your questions!
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.
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.
Are Medicare plans and requirements different for every state?
Medicare plans are different in regions even, so within a state, there will be multiple carriers offering multiple plans, sometimes differing zip code to zip code. Working with an independent broker, like myself, can help to widen your options and explore what will be best for you.I've been paying into Medicare for years, and I'm not sure why my specialist visits still cost me so much. What am I missing here?
Even with Medicare, specialist visits can cost money due to deductibles, coinsurance, and potential charges from non-participating providers. Medicare typically covers 80% of the Medicare-approved amount for most services, meaning you'll need to pay the remaining 20% (coinsurance) after meeting your deductible. Additionally, if your specialist doesn't accept Medicare assignment, they may charge you more than the Medicare-approved amount.
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.If I need hospice care in the future, can my Medicare plan cover it?
Yes, under Original Medicare Part A, you are eligible for hospice benefits if a doctor certifies that you are terminal illness. These benefits cover your cost, even if you are enrolled in a Medicare Advantage plan. However, you will still need Medicare Part B and pay the monthly premiums. Depending on your Medigap plan or Medicare Advantage coverage, you may have some out-of-pocket expenses.
Can you help me understand Maximum Out-of-Pocket (MOOP) limits in Medicare plans, from your experience as an agent?
There are two maximums out of pocket limits to consider.The first one is on prescription drugs.
In 2024, Medicare changed the way prescription drug plans work. Out with the old and in with the new $2,000 maximum amount you will pay for your covered prescription drugs. Our prescription drug plan insurance company keeps track of how much you've paid for your prescriptions and when you have reached your maximum, your covered prescriptions will drop to zero amount for the rest of the year.
The second maximum out of pocket to know about is with the Medicare Advantage plans.
If you have a Medicare Advantage Plan, commonly known as a Part C, the insurance company keeps track of how much you pay for co-pays and co-insurance through the year. Once you reach the plans maximum out of pocket amount, then the insurance company pays the remaining co-pays and co-insurance for the rest of the year. Each plan has a different Maximum out of pocket amount, so knowing what that amount is important.
Make note that if you only have original Medicare, there is no maximum out of pocket amount for your 20% co-insurance.
Isn't it suspicious that Medicare Advantage plans offer gift cards and incentives to enroll?
They are not allowed to offer incentives to induce enrollments. I advise prospects and clients to be wary of offers like this.
Don't you think Medicare's focus on treatment rather than prevention is backwards?
This is a complicated answer, how I look at it is Medicare is Based on Western Medicine that that focuses on treatment of conditions, so Medicare follow that process. However in my many years of doing this I have seen a lot of folks find out they have major health conditions because of the regular screenings that are at no cost to you on your policies. The plans do encourage you to use them and take advantage of no cost screenings and some doctor visits. So know that you are well covered. Now some plans do include no cost to you benefits, like gym memberships, access to over-the-counter products like vitamins and supplements, and other benefits that take aim at getting you and keeping you healthy! Make sure you choose a plan that fits your needs and lifestyle.Don't you think Medicare will eventually be privatized completely?
This is a considerable debate among Medicare beneficiaries and our government. The possibility of prioritizing Medicare is happening through the Medicare Part C Advantage plans, known as managed care under the supervision of major insurance companies. However, it is in the individual's choice to choose which direction they're going with Medicare. As Medicare Advantage plans continue to improve their services and networks of managed care, we will see more and more individuals moving in that direction.Suppose traditional Medicare Part A and Part B, with a Medigap plan, offered similar services like dental, hearing, and vision coverage to Medicare Part C advantage plans. In that case, they may not be as attractive. Traditional Medicare does not have in-network services, so you can use your benefits anywhere that they will take Medicare.
Don't you think Medicare's technology systems are outdated and inefficient?
Let's face it...almost everything about MEDICARE is confusing including the systems used to apply for MEDICARE...and then once you receive your PART "A" AND PART "B" card...how long would it take to figure out the right Plan for your unique situation?Did you know that using a local Independent Broker never costs you a fee and would make sure you get the right Plan for you.
Can you explain Special Needs Plans in Medicare?
There are people who have special circumstances that CMS has determined qualify for extra help and benefits.There are several different categories.
Dual Special Needs - Medicare / Medicaid eligible.
Chronic Special Needs - Those with listed health conditions
SNP - facility plasn - Those who are confined to a facility.
each case is different it is best to talk with a professional
Can you explain what "creditable coverage" means and when it applies?
As it regards to Medicare, creditable coverage for prescription drugs means that your current coverage is as good or better than what is provided under the standard Medicare Part D benefit. And upon proof that you have had creditable coverage under your current health plan, you can delay Medicare Part D enrollment without incurring the dreaded Part D enrollment penalty.
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).
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! WE can HELP YOU!
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?
Yes. After you`ve been on disability for 24 months, you should be automatically enrolled in Medicare in the 25th month.
I picked the plan with the lowest premium, but now every doctor visit feels like a surprise bill. Should I have gone with a higher premium instead?
Medica policies are very different from one another. You probably came up short with your needs analysis or listen to a friend who suggested their ““ Best” policy.A careful needs analysis and consideration for finances is the most appropriate way to determine which policy is “best” for you.
If you’d like assistance with this analysis, please contact me for a free consultation at 760-831-2736.
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?
Everyone has options to help with cost. We can evaluate your current cost and do a comparison to see what are the best options.
How do you stay up to date with changes in Medicare policies and plan options each year?
I listen to a weekly podcast that does a deep dive on the news and notes of the industry. I just got back from an insurance conference in Las Vegas to keep me up to date and make connections. Because of the way the industry is constantly changing you have to keep up to date of you will be left behind.
Does IRMAA go away automatically if my income drops, or do I need to report it to Social Security?
Completing your income tax return should change your recorded income for calculating IRMAA. Even with that being said, it makes sense to go ahead and attach your income tax form with an appeal to insure your surcharge is removed.My friend lives in a different city and has a much more detailed Medicare plan. Is their location dependent on their plan?
There should be little to no difference in coverage between traditional Medicare Part A and B and with a Medigap plan. Of course, some states require a few extra details in the Medigap plans, such as prevented care items.Medicare Advantage plans differ in some ways in providing requirements and services within and between states. These decisions are not Medicare decisions. They are based on the insurance carriers that provide these Advantage plans and the individual state regulations.
What's the deal with Medicare covering medical equipment like wheelchairs- do I need a special approval?
Medicare Part B covers durable medical equipment (DME) like wheelchairs when deemed medically necessary, but you must have a doctor’s prescription and obtain prior approval from Medicare to confirm it meets their criteria, such as being essential for use within your home. This includes items supplied by Medicare-approved DME providers, though many beneficiaries don’t realize this until a need arises, often prompting a last-minute call to advisors for clarification. Without proper approval, coverage won’t apply, and you’d face full costs, so verifying these requirements early is key.What's a common trick in Medicare marketing that hides restrictions on doctor choices?
Unscrupulous agents will not check networks providers and tell members their doctor takes the plan. This is why it is so important to meet with an agent in person.
How might artificial intelligence change how Medicare approves claims in the future?
AI will definitely be a part of claims decisions in the future, but it will not be the end all as you will always have the ability to appeal to a real person.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.
Is Medicare becoming more expensive over time, and will it ever be unsustainable?
As the cost of medical care increases with inflation, so will the cost of medical insurance premiums, deductibles, coinsurance, and co-pays. Whether it will ever become unsustainable is a question that only time can honestly answer. What is the future of America's healthcare costs?Why does Medicare have so many coverage gaps, and is it designed that way on purpose?
In 1965, the government set up Medicare to help primary care for those over 65 with healthcare costs. President Johnson set it up to share healthcare costs between the government and beneficiaries. This was called the cost-sharing approach, with the intent to help control Medicare abuse and overcharge by discouraging unnecessary use of the services.Today, with healthcare costs rising, the original design has revealed six major gaps in its coverage. Therefore, yes, I think it was designed this way in the beginning, which makes it very confusing today. You need to make sure you have the right coverage and can’t afford the coverage of these gaps.
Why did I receive a Medicare Summary Notice, and what should I do with it?
Your plan changes every year. That is why you need to make sure and have your agent quote even if your plan is currently working for you.
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.Why does Medicare allow insurance companies to bombard seniors with confusing mail and TV ads?
Medicare agents can solicit customers through marketing advertisements and mail, but cannot make unwanted phone calls if you are on the do-not-call list. These calls are not legal! The marketing of Medicare Advantage plans is often very aggressive, and it is recommended that you do not act in haste when dealing with these plans. Medicare Advantage plans can be a very accessible and rewarding substitute for traditional Medicare with a Medigap plan. However, these plans must be carefully considered in conjunction with your in-network physicians and other healthcare providers you may be using in your area.
My husband passed away and now my Medicare premiums went up. Why does losing someone raise your costs?
This can be complicated. It has to do with you & your husband's "Adjusted Gross Income" or "AGI" which is taken from your 2-yr. old tax return. If you've earned more than your husband during your respective careers, once he is out of the picture, Medicare only looks at your new and "individual" tax return. The least amount in 2025 for the Part B premium is $185.00 (as an individual filer, that means the "AGI" is $103,000.00 or less; but it can be as much as $594.00 per month if your AGI is $500K or greater). My best advice for you would be to make an appointment with a counselor at your nearest Social Security office to verify that the above example happened to be your case, or not.
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.
How do I budget for Medicare costs if I expect my health to decline in the next decade?
I’ve always stated that you should plan with good health coverage, but budget for today. It is difficult to project the future outcome of your health, but getting the right coverage in Medicare today can help alleviate expensive costs in coverage for tomorrow.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 clientsWon't Medicare run out of money before I can benefit from it?
My succinct answer is NO! Don’t listen to those “scare tactics”. I recently saw that there is enough until around 2040.
Isn't Medicare headed for a crisis with so many baby boomers aging into the system?
This is known very well by the Medicare market and it is pretty much going to hit its peak by 2030. This is not a surprise as it’s been known for a very long time. There may be changes and adjustments made but it isn’t going to blindside the industry.
What are the 6 things Medicare doesn't cover?
Original Medicare does NOT typically cover: Please see pages 55-56 in your 2025 Medicare and you Handbook. If you want a digital copy, contact me and I will be happy to forward by email.1. Cosmetic Surgery
2. Massage Therapy
3. Hearing Aids and Exams
4. Routine Dental Care
5. Concierge Care
6. Eye Exams (for Prescription Glasses)
Good news is that some of these are covered in a Medicare Advantage plan. Dental/Vision can be covered in a Standalone Dental/Vision plan.
Contact a local broker to confirm these coverages in your local plan.
How do I report a suspicious Medicare billing error without getting in trouble myself?
Don't let the fear of retaliation prevent you from exposing the possible wrongdoing of someone in a position of trust over you. The False Claims Act protects you.Fraud, waste, and abuse hurts us all. It takes courage to report something you think is wrong, but it's the right thing to do. We all must do our part to expose corruption in the system because, in the end, it's our money being misused.
To report something you think is wrong, you have several options. You can call your provider's office and inquire about the charge. They may be able to explain it. If you feel uncomfortable or sense your concern was brushed off, call your plan's member services number and speak with a supervisor about the billing error. You may also call Medicare to voice your concerns. These actions take time, but after you call, you'll feel better knowing you did the right thing.
How will advancements in wearable health tech (like smartwatches) integrate with Medicare?
Advancements in wearable health technology are poised to significantly enhance patient care and facilitate faster diagnoses. By continuously monitoring vital metrics such as heart rate, blood pressure, glucose levels, oxygen saturation, and sleep patterns, these devices provide valuable data that can be shared with healthcare providers. This allows for more efficient coordination of care and timely follow-up.How could a universal healthcare debate shift Medicare's structure in the next decade?
In all honesty I have no idea how or what could happen in the next decade. There are changes to the Medicare marketplace every year but I have no idea what could change over the next 10 years
Would expanding Medicare to younger Americans improve or hurt the program?
I think that Medicare should stay right where its at. 65 and older, or younger with disability. I don't feel it should be for everyone.Don't you think Medicare should ban all those celebrity Medicare Advantage commercials?
I think it's their right to make commercials. If they are giving false information and misleading people to think that all plans come with $1,800 in grocery benefits every year, they need to make those things clear. I just make simple commercials and educational videos, which seem to work!Isn't it time for Medicare to completely overhaul how it approaches senior care?
This is a long-time debate. Some feel we need to privatize Medicare, and others feel we need to let the government control it under a one-plan-for-all. Health decisions are very private, and with that being said, many areas in the Medicare system need to be adjusted or approved, along with the idea of using newer technology.I worked for the federal government for 30 years and took early retirement. How does my federal retirement affect my Medicare options?
Well that depends on a lot of factors. If you are not 65 then you don't have an option to get on medicare unless you are diagnosed with a disability.If you are 65 and the your coverage will stop at 65 then you need to get on medicare part A and
B.
If you are 65 and the government is giving you lifetime coverage then you need to see if it is worth paying the medicare part B premium and adding medicare or just staying on your current coverage.
Can I enroll in Medicare if I've never paid into Social Security due to working overseas?
Anyone legally in the United States can enroll into Medicare if they are at least 65 years old or if they have been deemed disabled for the last 24 months by a physician. Someone that has worked overseas and not paid into the system may have to pay a premium for Part A (Hospital coverage) of Medicare, that people who have paid into the system get it premium free.How might climate change-related health issues (like heat stroke) influence Medicare policies?
In my 25 years working with Medicare, climate change-related health issues like heat stroke have never come up in discussions or policy updates—not once. Honestly, it’s not something I’ve ever thought about either, but I’d assume it wouldn’t shift Medicare coverage much since conditions tied to it are already baked into what’s covered. Any impact would likely stay minor, handled within existing frameworks.
What's the projected impact of an aging population on Medicare Part A hospital funds?
I just searched online and the second article listed was written in 2008 and stated that Medicare Part A will have insufficient funds by 2019. Be careful of the information you read online. It's good to be informed but don't get caught in the weeds or buy into fear-based articles. If you called Medicare I would guess they would not be able to answer that question, other than Part A funds must be increased every year.What role might private insurers play if Medicare expands to cover more preventive care?
Private insurers will play a major role if Medicare expands its preventative care coverage, like offering many more "extra services" and benefits all centered around prevention. Currently almost all Medicare Advantage Plans and private insurers have some type of dental coverage, whether that be preventative checkups and maintenance to a more robust offering of basic and major services like fillings, crowns, deep cleanings, etc.How do I appeal a decision by Medicare or my plan if they deny coverage for a procedure or medication I need?
To appeal a decision by original Medicare, contact Medicare. If your Part D plan is denying prescription drug coverage, have will need to request that your doctor file for a "formulary exception" with your insurance. If the insurance company decision is to deny the requested exception, you need to feel an appeal with your insurance. The recommended plan of action for an insurance company's denial of coverage for a specific procedure is you need to contact your insurance company and file an appeal of the denial. Your independent Medicare health insurance agent (who sold you the plan) most assuredly should be able to help you.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.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.
