Who’s Eligible for Medicare at 65?

Most people become eligible for Medicare when they turn 65—but eligibility hinges on one key requirement: 40 quarters (or 10 years) of work history with contributions to Medicare. If you’ve worked enough, you’ll qualify automatically. But what if you stayed home to raise a family or served as a caregiver?

In those cases, you may be able to qualify using your spouse’s—or even ex-spouse’s—work history. The rules are specific: you must be married to your current spouse for at least one year or to your ex-spouse for at least 10 years. If you’re divorced, you must also remain unmarried before age 60 to qualify under their record. These small details can have a huge impact on your eligibility and what you pay.

What If You Don’t Have 40 Quarters?

Here’s the breakdown:

• If you have 30–39 quarters, Medicare Part A will cost you $285/month in 2025.
• Less than 30 quarters? You’ll pay $518/month.

My advice? If you’re close to the 40-quarter mark, keep working part-time. In 2025, you’ll get credit for one quarter for every $1,810 you earn—so it’s very doable!

When and How to Enroll in Medicare

Your Initial Enrollment Period (IEP) starts three months before your 65th birthday, includes your birthday month, and extends three months after. If you sign up early, your coverage starts on the first day of your birthday month. Enroll later, and your start date could be delayed.

Still working? You may qualify for a Special Enrollment Period (SEP) when you retire or lose employer health insurance. But remember: COBRA doesn’t count as credible coverage, so don’t rely on it to delay Medicare. You’ll need to complete forms L564 (for employer verification) and CMS 40B (to apply for Medicare Part B).

Working Past 65? Know Your Options

If you’re still employed and have coverage through a company with 20+ employees, you might not need to enroll in Medicare right away. But be careful—if you have a Health Savings Account (HSA), enrolling in Medicare Part A will disqualify you from making further HSA contributions. That’s why I often recommend reviewing your employer’s coverage against Medicare. Consider factors like premiums, co-pays, deductibles, and your out-of-pocket maximums. Sometimes, Medicare is the better deal!

Medicare Supplement vs. Medicare Advantage: Which Should You Choose?

Here’s a breakdown of the two main Medicare paths:

Supplement Plans

• Use any doctor that accepts Medicare
• Nationwide coverage—great for travelers
• No referrals needed
• Consistent costs: around $150–$180/month + $257 annual Part B deductible
• Lifetime coverage as long as premiums are paid

Advantage Plans

• Lower or $0 monthly premiums
• Local network restrictions
• May require referrals or prior authorizations
• Plans vary by zip code and can change when you move
• Higher potential costs during major medical events

In short: Supplement plans offer predictability and freedom. Advantage plans may fit a tighter budget but require more careful planning. Think about your travel habits, medical needs, and finances before choosing.

Need Help? You’re Not Alone

Every Medicare journey is unique, and I’m here to guide you through it. At MedicareSchool.com, we provide personalized advice to help you understand when to enroll and which plan works best for you.

Don’t wait until the last minute—Medicare is too important to wing it. Get the facts, plan ahead, and make confident choices for your future.

The post Navigating Medicare at 65: Eligibility, Enrollment, and Choosing the Right Plan appeared first on ROI TV.

Let’s break it down, because depending on the type of vaccine and how it’s given, Medicare covers them under Part A, B, C (Advantage), or D. Here’s everything you need to know.

Medicare’s Vaccine Coverage by the Numbers

Medicare allocates roughly $5 billion annually for vaccines. This massive investment is meant to prevent hospitalizations, protect seniors, and reduce long-term healthcare costs. But not all vaccines are covered the same way.

Medicare Part A and B: What’s Covered for Free?

Medicare Part A doesn’t usually cover outpatient vaccines—it’s focused on inpatient care like hospital stays. But if a vaccine is administered during a hospital visit, it might be included.

Medicare Part B, however, is where most preventive vaccines are fully covered. If your doctor or provider accepts Medicare, these vaccines come at no cost to you:

• Flu Vaccine – One shot per flu season (and there are now two flu seasons each year). Medicare spends $1 billion treating flu complications annually.
• Pneumonia Vaccine – Given in two doses. Pneumonia costs Medicare $13 billion each year.
• Hepatitis B Vaccine – Covered if you’re at medium or high risk, such as living with diabetes or undergoing dialysis. Medicare spends about $2 billion on Hep B treatment annually.
• COVID-19 Vaccine – All doses and boosters are 100% covered. Medicare spends $2 billion per year here too.
• Rabies Vaccine – Covered by Part B only if you’ve been exposed (like after an animal bite).

Medicare Part D: Self-Administered or Pharmacy-Based Vaccines

Part D plans handle vaccines typically administered at the pharmacy or as self-injectables. Thanks to recent policy updates, all of these vaccines are now covered at zero cost:

• RSV (Respiratory Syncytial Virus) – Newer to the market but fully covered. Medicare spends $6.6 billion annually on RSV-related care.
• Shingles (Zoster) – Medicare Advantage and Part D plans now cover this entirely, saving you from the usual $200/dose.
• Tdap (Tetanus, Diphtheria, Whooping Cough) – Covered under Part D unless given for an injury (then it’s Part B).
• Hepatitis A & Combo Vaccines (like Twinrix) – Covered through Part D.
• MMR (Measles, Mumps, Rubella) – Fully covered under Part D.
• Varicella (Chickenpox) – Covered under Part D.
• Travel Vaccines – Covered only if ACIP and the CDC recommend them for your destination.

How Are These Vaccines Approved for Medicare Coverage?

The Advisory Committee on Immunization Practices (ACIP)—a 55-member panel housed under the CDC—recommends which vaccines Medicare should cover. The group meets three times a year and includes physicians, scientists, and public health officials.

Once ACIP makes a recommendation, it is adopted by the CDC and then by Medicare.

Medicare Advantage Plans (Part C)

Most Medicare Advantage Plans follow the rules set by Parts B and D. However, you’ll need to use in-network providers to avoid out-of-pocket costs, and some plan benefits may vary slightly. Always review your plan’s coverage annually.

Why This Matters: Vaccines Prevent Expensive Problems

Treating diseases like flu, RSV, or shingles can cost Medicare (and you) thousands. For example:

• The average RSV hospitalization for seniors costs $50,000.
• A shingles outbreak could lead to chronic nerve pain and other complications.
• Influenza hospitalizations alone cost $12,000 each.

Medicare’s preventive vaccine coverage aims to keep you healthy and out of the hospital, while also lowering long-term healthcare costs across the board.

Need Help Navigating Medicare?

The Medicare Essentials Workshop helps beneficiaries understand when to enroll, how to pick the right plan, and how to avoid costly enrollment mistakes. It also covers vaccine benefits and what steps you should take to maximize your preventive care.

Bottom Line: So How Many Vaccines Are 100% Covered by Medicare in 2025?

At least 10 core vaccines—including flu, pneumonia, COVID, shingles, RSV, and more—are fully covered under Part B or Part D with zero out-of-pocket costs. That’s a major win for seniors who want to stay healthy without financial strain.

If you’re 65+ or caring for someone who is, now’s the time to take full advantage of Medicare’s preventive coverage. It’s not just about protection—it’s about peace of mind.

The post How Many Vaccines Are 100% Covered by Medicare in 2025? appeared first on ROI TV.

Why COBRA Isn’t a Substitute for Medicare at 65
COBRA lets you keep your employer’s group health plan for a limited time after you leave your job—typically 18 months. While that sounds like a helpful safety net, it becomes dangerous when you hit 65. Once you turn 65, Medicare becomes the primary payer, and COBRA automatically becomes the secondary payer. That means if you haven’t enrolled in Medicare yet, COBRA won’t cover most of your medical bills. Imagine being stuck with 80% of a $100,000 hospital bill because you didn’t enroll in Medicare on time. That’s why you must enroll before your 65th birthday if you’re on COBRA.

The Initial Enrollment Period (IEP): Your Best Opportunity
Your IEP is the seven-month window that includes the three months before your 65th birthday, the birthday month, and three months after. If you’re on COBRA, enrolling during the three months before your birthday ensures Medicare coverage begins the first day of your birthday month. Wait too long, and you could have a dangerous coverage gap where you’re financially exposed.

Special Enrollment Period (SEP) for Those Retiring After 65
If you’ve continued working past 65 and had credible coverage through your employer, you get an SEP when you retire. This lets you enroll in Medicare without a late penalty—but only if you file the right forms promptly. You’ll need Form L564 (to prove you had credible coverage since turning 65) and Form CMS 40B (to request your Medicare start date). Timing matters here too—if your employer coverage ends June 30, your Medicare should start July 1 to avoid a lapse.

Don’t Miss the Medigap Open Enrollment Window
Once you enroll in Part B, you get a six-month Medigap Open Enrollment Period (OEP). During this time, you can sign up for supplemental plans like Plan G or Plan N with no medical underwriting. That means no health questions, no exclusions, and guaranteed approval. But once that window closes, it’s a different story. Applying later means answering 20–25 health questions and possibly getting denied based on your medical history.

Supplemental Plans Add Critical Protection
Even with Medicare Parts A and B, you’ll face deductibles and coinsurance. That’s where Plan G or Plan N come in. These supplemental plans pick up where Medicare leaves off and can save you thousands. But again, the key is to enroll during your Medigap OEP. Miss it, and your options could be limited or unavailable entirely, depending on your health.

The Biggest Risk: Gaps in Coverage
The biggest mistake I see? People assuming COBRA will fully protect them after 65. It won’t. As soon as you’re eligible for Medicare, COBRA becomes secondary. And if you haven’t enrolled in Medicare, you’re left holding the bag. You must align your Medicare start date with your COBRA end date or risk a gap in coverage that could cost you tens of thousands of dollars.

My Recommendations Are Simple
Enroll in Medicare before you turn 65 if you’re on COBRA. If you’re working past 65, use the SEP and submit Forms L564 and CMS 40B on time. And once you have Part B, take full advantage of the Medigap Open Enrollment Period. These steps can mean the difference between financial security and a lifetime of regret.

The post COBRA and Medicare: What You Must Know Before Turning 65 appeared first on ROI TV.

In this week’s episode, we broke down how Medicare Part D works, what’s changing in 2025, and how to make sure you’re getting the best deal on your medications. Whether you’re managing a chronic condition or just want to avoid unnecessary spending, these updates could save you thousands.

The Push for Lower Drug Prices: Most Favored Nation Pricing

Back in 2020, President Trump signed an executive order that aimed to lower U.S. drug prices by tying them to the prices paid in other developed countries—a strategy called “most favored nation pricing.”

Here’s what that could look like:

• Ozempic costs $936/month in the U.S.
• In Japan? $169
• In the UK? $93
• In Australia? $87
• In France? $83

That’s not a typo—U.S. patients are paying over 10x more for the same drug. The goal of this order was to pressure pharmaceutical companies to cut prices or face big caps on their Medicare earnings.

Understanding How Medicare Part D Works

Medicare Part D plans are split into three cost phases:

1. Deductible Phase
   • You pay 100% until you meet the deductible (up to $590 in 2025)
   • Tier 1 & 2 drugs may be exempt
2. Initial Coverage Phase
   • You pay 25% of drug costs
   • Your plan covers the rest—75% for generics, 65% for brands, Medicare covers 10%
3. Catastrophic Phase (starting in 2025)
   • Once you hit $2,000 in out-of-pocket costs, you pay $0 for the rest of the year
   • The cost burden shifts: 60% insurers, 20% Medicare, 20% manufacturers

The Inflation Reduction Act: What It Means for You

The Inflation Reduction Act of 2022 is a game-changer for Medicare drug coverage:

• $2,000 out-of-pocket cap starting in 2025
• Eliminates the 5% coinsurance in catastrophic coverage
• Capped insulin at $35/month through the senior savings model
• Begins government negotiation of drug prices starting in 2026

What kind of savings are we talking about?
Drugs like Eliquis, Xarelto, Farxiga, and Enbrel are expected to drop in price by 38% to 79%.

What the Industry Thinks

Pharmaceutical companies are pushing back, claiming these reforms will hurt innovation and cut funding for research. Some experts say that while Medicare might save billions, patients may not feel the full benefit immediately.

There’s also concern that other countries may face price hikes as companies try to balance out lost revenue from the U.S. market.

Medicare Part D Premiums: What’s the Trend?

Despite inflation, premiums for Medicare Part D have stayed relatively steady:

• 2006 average: $26
• 2025 average: $45

But premiums vary widely. Some plans are as low as $0/month, while others go up to $133/month depending on the drugs you take.

5 Cost-Saving Tips for Medicare Beneficiaries

If you’re on Medicare, here’s what you can do to save on prescriptions right now:

1. Review Your Plan Every Year
   Use the Annual Enrollment Period (Oct 15–Dec 7) to switch plans if needed. Your current plan might not be your best option in 2025.
2. Bring Your Formulary List to Doctor Visits
   Ask if there’s a covered alternative that works just as well.
3. Check for Extra Help
   If you’re still struggling after hitting the $2,000 cap, apply for Extra Help at ssa.gov. It can dramatically reduce premiums and co-pays.
4. Shop Smart During the Deductible Phase
   Ask your doctor about generics or Tier 1/Tier 2 drugs that are often exempt from deductibles.
5. Prepare for 2026 Drug Price Negotiations
   Keep an eye on high-cost prescriptions. If you’re taking one of the targeted drugs, price relief could be coming soon.

The Future of Drug Pricing and Medicare

We’re heading into a period of major change. The goal is to reduce costs for patients and the government, but some of the biggest savings may take time to reach your pharmacy counter.

In the short term, seniors who take expensive medications for chronic conditions will see the most relief. Over time, as government negotiations kick in, broader savings should start to show.

Final Thoughts

Prescription costs are one of the biggest stressors for retirees—but they don’t have to be. With Medicare Part D reforms, the Inflation Reduction Act, and some smart planning, you can take back control.

The $2,000 cap is just the beginning. Stay informed. Review your plan. And don’t miss open enrollment.

The post New Executive Order Could Bring Significant Change To Medicare Drug Plans appeared first on ROI TV.

Let’s break down the key reasons for this surge, and the smart strategies you can use to protect your retirement income.

1. What’s Driving Medicare Costs Higher in 2025

Several key trends are pushing Medicare premiums higher than ever:

• Medical Inflation Outpacing General Inflation: Health care costs are rising faster than the general rate of inflation, especially for services covered by Medicare like surgeries, specialist visits, and hospital stays.
• Post-COVID Care Catch-Up: Many people delayed medical care during the pandemic. Now, as patients return for surgeries, diagnostics, and checkups, Medicare is footing a much larger bill—causing premiums to spike.
• Expensive Brand-Name Medications: The widespread use of costly drugs for diabetes and weight loss like Ozempic and Wegovy has strained Medicare’s budgets.
• Mental Health Coverage Expansion: Medicare now offers more comprehensive mental health benefits, but with increased access comes increased usage and higher costs.
• Aging Population: Baby boomers continue to enter Medicare in large numbers, and as they age, they use more health care services further driving demand and cost.

2. How to Reduce Your Medicare Costs: Plan Switching Strategies

There are ways to combat these rising costs by re-evaluating your current plan options:

• Switch from Plan F to Plan G or N: If you’re still on Plan F (which covers everything), consider switching to Plan G or N. You may lose a few minor benefits but could save hundreds annually.
• Compare Insurance Carriers: Even if you stay with the same type of plan, switching to a different insurance provider can yield lower monthly premiums for identical coverage.
• Consider Medicare Advantage: These all-in-one plans (often HMO or PPO) usually have lower premiums and may include extras like dental, vision, or gym memberships—but come with networks and prior authorization requirements.
• Returning to Supplemental Plans: If you’re unhappy with a Medicare Advantage plan, you may be able to switch back to a Medigap plan—but underwriting could apply unless you’re in a state that offers special switching rights.

3. Understand Your Rights: Enrollment Windows Matter

Timing is everything when it comes to Medicare. Here’s what to know:

• Medigap Open Enrollment Period: When you first enroll in Medicare Part B, you get a 6-month window where you can enroll in any Medigap plan without underwriting, even with preexisting conditions.
• State-Specific Switching Rules: Some states allow special switching windows where underwriting is waived:
  • Birthday Rule: States like California, Oregon, and Nevada let you switch to like or lesser coverage within 30–60 days of your birthday.
  • Anniversary Rule: Missouri allows switching on your plan’s anniversary.
  • Year-Round Switching: New York, Connecticut, and Massachusetts offer continuous guaranteed issue rights.

4. Understand How Medigap Plans Are Priced

There are three ways Medigap plans are priced, which can impact how much you pay now and in the future:

• Community-Rated: Everyone pays the same, regardless of age. Increases are only based on claims from the group. Used in 9 states.
• Issue-Age-Rated: Your initial premium is based on the age you were when you enrolled, but it doesn’t rise as you age. Found in 4 states.
• Attained-Age-Rated: The most common pricing method premiums start lower but increase as you age and as group claims rise. Used in 37 states.

Knowing which model your state uses can help you plan for future affordability.

5. Get Help: Medicare Brokers and Tools

Don’t try to navigate Medicare alone there’s free help available.

• Licensed Medicare Brokers: These professionals represent multiple insurance carriers and can help you compare plan costs, switch plans, and even resolve billing issues after enrollment. They don’t charge you for their services.
• Online Tools: Platforms like Medicare.gov or independent quote engines like Metagapare.com allow you to compare prices, plans, and coverage features side by side.

Conclusion: Don’t Let Rising Costs Derail Your Retirement

Rising Medicare premiums are real but so are your options. By proactively exploring plan types, knowing your state’s switching rules, and leveraging free professional help, you can protect your health coverage and your wallet.

Stay informed, ask questions, and take action during enrollment windows. What you save could fund your next vacation—or simply buy you peace of mind.

The post Why Medicare Costs Are Rising in 2025 and What You Can Do About It appeared first on ROI TV.

New Tools to Combat Fraud

One of the SSA’s primary focuses is combating direct deposit fraud, which accounts for nearly 40% of all Social Security fraud cases. According to reports from the Epoch Times, over 20,000 beneficiaries had their funds misdirected between January 2013 and May 2018. To address this, the SSA has introduced a “final identity proofing policy” that employs algorithms to flag unusual account activity, prompting further review or in-person verification when necessary.

Importantly, these changes do not require all beneficiaries to visit Social Security offices in person. The goal is to protect identities without disrupting the application and benefits process for most people.

Understanding Common Fraud Tactics

Fraud within the Social Security system is typically committed by individuals misreporting income or living arrangements—for example, claiming to live alone to reduce rent obligations or hiding earnings while collecting benefits. While identity theft is a concern, these types of misrepresentation remain the more common offenses.

Operational Changes at Social Security Offices

To support the new identity verification requirements, the SSA has mandated that all employees work in-office five days a week. This change is intended to reduce long lines, improve staff availability, and increase efficiency in local Social Security offices. Additionally, updates to direct deposit information will now be processed in just one day, down from the previous 10-day timeline.

Policy Changes for Supercentenarians

To prevent fraudulent claims by individuals falsely reporting their age, the SSA now requires anyone over the age of 115 to verify their identity in person to continue receiving benefits. This new policy closes a loophole that had previously allowed claims to go unchecked due to record discrepancies.

A Refresher on Social Security Benefits

Social Security provides four primary types of benefits:

• Disability Benefits for individuals with medical conditions that prevent them from working.
• Retirement Benefits available from ages 62 to 70, with early withdrawals reducing total payouts.
• Spousal and Dependent Benefits, offering 50% of a spouse’s benefit to the other partner and eligible dependents under age 18.
• Survivor Benefits granting 100% of a deceased spouse’s benefit to the surviving partner.

Medicare and Social Security Online Applications Remain Accessible

Despite the new fraud prevention measures, online applications for Medicare and Social Security remain open and user-friendly. Beneficiaries can continue to apply from home and receive assistance from trained Medicare guides to help avoid mistakes and navigate complex eligibility rules.

Boosting Operational Efficiency

The SSA’s new policy rollout was delayed until April 14th to ensure a smooth transition. Now fully implemented, these changes aim to improve service delivery, expedite direct deposit updates, and reduce identity theft risks through consistent staffing and better technology.

Clarifying Longevity Claims in Social Security

Discussion also addressed the myth of super-longevity in “blue zones,” areas where individuals are believed to live past 110 years. In many cases, these claims result from medical record errors. The SSA has taken corrective action to ensure that age verification is accurate and benefits are properly distributed.

Take Action: Stay Informed and Protect Your Benefits

Beneficiaries are encouraged to stay updated on Social Security policies and report any signs of identity theft or fraud to their local SSA office. Assistance from Medicare guides is also available to help beneficiaries make informed decisions and avoid costly mistakes in both Social Security and Medicare enrollment.

The post New Social Security Fraud Measures Aim to Improve Security and Efficiency appeared first on ROI TV.

Let’s break down what this change could mean for you or your loved ones.

What’s Being Proposed?

The proposal would automatically enroll eligible individuals into a Medicare Advantage (MA) plan unless they actively opt out. These plans, run by private insurers, already cover more than half of all Medicare beneficiaries—34 million out of 67 million in 2024. Supporters believe default enrollment could reduce missed deadlines and ensure people receive more comprehensive coverage, especially those unaware of the complexities of Medicare enrollment.

But critics argue it could cost taxpayers billions and reduce people’s ability to choose the right coverage for their personal health and financial needs.

How Medicare Enrollment Works Today

Currently, when someone becomes eligible for Medicare, they must actively enroll in Part B and decide between two main coverage paths:

1. Traditional Medicare (Parts A & B) plus a standalone Part D plan and an optional Medigap supplemental plan.
2. A Medicare Advantage plan, which bundles Part A, Part B, often Part D, and additional perks like dental, vision, and gym memberships.

MA plans offer broader benefits but often come with prior authorization requirements, limited provider networks, and restrictions on specialist access. Traditional Medicare provides broader provider choice with fewer hurdles, but beneficiaries must actively seek supplemental coverage to avoid out-of-pocket costs.

The Benefits of Default Enrollment

Proponents of default enrollment point to several advantages:

• Fewer Missed Deadlines: Enrollment deadlines during the Initial and Special Enrollment Periods can be confusing. Defaulting into an MA plan could ensure people aren’t left without essential coverage.
• Comprehensive Benefits: MA plans often offer added perks not included in Original Medicare, such as vision, dental, and hearing.
• Simplified Process: Automatically enrolling new beneficiaries could make the system easier to navigate for those overwhelmed by Medicare’s many parts and rules.

The Downsides: What Could Go Wrong?

While the idea may sound convenient, default enrollment comes with significant trade-offs:

• Provider Access: MA plans have smaller doctor and hospital networks. Default enrollment may place someone in a plan that excludes their preferred providers.
• Mismatched Drug Coverage: Beneficiaries may find their prescriptions are not covered or require higher out-of-pocket costs if the default plan’s formulary isn’t aligned with their needs.
• Freedom of Choice: Automatically assigning a plan could compromise individuals’ right to shop around for a better fit. While they can opt out, many may not realize they have that option.
• Increased Red Tape: Prior authorizations and referrals, common in MA plans, could delay treatment and frustrate both patients and providers.

What About the Cost?

Financially, default enrollment could be costly:

• The federal government already spends 20% more per person on Medicare Advantage enrollees than on those in traditional Medicare.
• That extra cost translates into $84 billion in excess spending projected for 2025 and up to $269 billion over the next decade.
• Beneficiaries could also feel the pinch. Medicare Part B premiums rose from $144.60 in 2020 to $185 in 2024, in part due to higher federal spending.

For comparison, a traditional Medicare + Plan G supplement provides predictable coverage with a monthly premium of $150–$180 and a fixed annual deductible ($257 in 2024), avoiding the uncertainty and limitations of MA plans.

Is This Even Legal or Feasible?

Any major change like this must go through the Center for Medicare & Medicaid Innovation (CMMI), which is tasked with testing new models that improve care without raising costs. It’s unclear whether this proposal meets those criteria. A rollout would require:

• Pilot Testing: Regional or national pilots to determine impact on cost and care quality.
• Fair Plan Assignment: Beneficiaries must be matched with suitable plans, ideally factoring in healthcare needs and geography.
• Clear Communication: Opt-out processes, plan summaries, and doctor network information must be transparent and accessible.

Final Thoughts

The idea of default enrollment in Medicare Advantage plans may sound like a step toward simplifying healthcare. But under the surface, it’s far more complicated and potentially expensive. While it could help ensure more people are covered, it also risks undermining individual choice and creating administrative headaches for patients and providers alike.

For now, the best strategy is to stay informed and review your Medicare options carefully. Whether you prefer the flexibility of traditional Medicare or the added perks of a Medicare Advantage plan, the key is understanding the pros, cons, and costs of each.

The post Should Medicare Advantage Be the Default? What a New Proposal Could Mean for You appeared first on ROI TV.

Here’s why so many doctors are frustrated with the current state of Medicare Advantage—and what patients need to understand before choosing a plan.

1. Administrative Burdens Delay Patient Care

Doctors overwhelmingly cite prior authorizations as one of the most frustrating elements of Medicare Advantage. These plans often require approval for a wide range of services, including basic lab tests, MRIs, outpatient surgeries, and even prescription medications.

To navigate this red tape, the average medical practice must employ at least two full-time staff members just to handle prior authorizations. This administrative burden increases overhead costs and takes time away from patient care. And with over 3,800 MA plans in the market, each with its own unique rules, even seasoned providers struggle to keep up.

In contrast, Original Medicare and supplemental Medigap policies rarely require prior authorizations, resulting in fewer delays and a smoother experience for both patients and providers.

2. Lower and Slower Reimbursements Hurt Practices

Medicare Advantage plans typically reimburse doctors at about 85% of what they’d receive under Original Medicare. Not only are payments lower, but they’re also slower. While Medicare pays claims within weeks and Medigap plans within days, MA plans often delay payments for weeks or even months, putting financial stress on smaller practices.

This reimbursement gap makes it harder for providers to sustain their practices, especially those serving a high volume of MA patients. Many report losing money on certain procedures or patients due to these reduced rates.

3. Limited Provider Networks Frustrate Patients and Providers

One of the most common complaints about Medicare Advantage is its restricted provider networks. Unlike Original Medicare, which is accepted by 99% of non-pediatric physicians and nearly all hospitals nationwide, MA plans use HMO and PPO networks that significantly limit provider choice.

Studies show that only 22% of MA plans give access to 70% of doctors in a metro area. Worse, 43% of plans limit access to just 50% of doctors. These limitations make it difficult for patients to keep their preferred providers and often force them to switch plans or pay out-of-pocket for care.

4. Denials of Necessary Care Are Far Too Common

Government audits have found that Medicare Advantage plans deny medically necessary care more often than Original Medicare. From delaying knee replacements and chemotherapy to refusing approval for PET scans and stents, the consequences of these denials can be severe.

Doctors argue that these decisions often come from insurance administrators rather than clinicians. This not only undermines their professional judgment but also puts patients at risk by delaying critical treatments.

5. Profit-Driven Policies Undermine Medical Judgment

MA plans use utilization management tools—such as step therapy, quantity limits, and algorithm-driven care decisions—to cut costs. Unfortunately, these systems often prioritize insurer savings over patient well-being.

For example, some MA plans prematurely discharge patients from skilled nursing facilities, regardless of medical advice. Others require patients to “fail first” on cheaper medications before authorizing the doctor’s recommended treatment. These policies not only frustrate doctors but also jeopardize outcomes.

6. Real-Life Consequences of Medicare Advantage Barriers

The data may be compelling, but the real-world stories are even more telling:

• A breast cancer patient experienced delayed treatment when her MA plan denied a PET scan, allowing her cancer to progress.
• A cardiac patient waited overnight in the ER for MA approval for a stent—a delay that risked his life.
• A patient with severe depression was left waiting three months to see an in-network psychiatrist.
• A hip surgery patient was discharged early from rehab due to plan limits, only to fall at home and suffer a hip fracture.

Each of these cases underscores how insurance interference can create dangerous and unnecessary hurdles.

7. What Doctors Are Saying Across Specialties

• Primary care doctors: Report heavy paperwork and difficulty getting even routine tests approved.
• Cardiologists: Face delays for stress tests, imaging, and post-operative medications.
• Oncologists: Experience frequent denials for advanced imaging and lifesaving chemotherapy.
• Orthopedic surgeons: Encounter delays for MRIs, surgeries, and rehabilitation.
• Mental health providers: Battle limited access to psychiatrists and prior authorizations for medications.
• Geriatric care specialists: Warn of tight limits on home health care and skilled nursing, even when patients clearly need more support.

Final Thoughts: What Patients Should Know

While Medicare Advantage plans may offer lower premiums and appealing extras like dental or vision, it’s important to weigh those perks against the real-world consequences. If your doctor is reluctant to accept your plan or you face frequent delays in care, those savings may come at a high cost.

Doctors aren’t just complaining for the sake of it. They’re raising alarms because these plans often interfere with their ability to care for patients effectively. If you’re considering Medicare Advantage, take the time to understand how your access to care—and your doctor’s ability to provide it—might be affected.

The post The Hidden Costs of Medical Care appeared first on ROI TV.

2. Understanding Medicare Parts and How Part D Fits In
Medicare is split into four parts:

• Part A: Covers hospital stays
• Part B: Covers outpatient care and certain administered medications
• Part C (Medicare Advantage): Bundles A and B, often includes Part D
• Part D: Covers self-administered prescription drugs

If you’re using Original Medicare (Parts A and B), you can add Part D as a standalone plan. If you have a Medicare Advantage plan, it may already include drug coverage.

3. How and When to Enroll
Enrollment is open to anyone who qualifies for Medicare Part A or B. Your initial enrollment period spans seven months: three before, the month of, and three after you turn 65. Miss it, and you may pay penalties. There are also special enrollment periods if you lose employer coverage or qualify due to life changes.

4. When Can You Switch Plans?
Standalone Part D plans can be switched annually during Open Enrollment (October 15 to December 7). Medicare Advantage plans with Part D can also be changed from January 1 to March 31. Many people switch due to changes in medications or plan formularies.

5. The Real Cost of “Free” Plans
Plans advertising $0 premiums may not actually be the cheapest. One case showed that a $97 monthly premium plan cost less annually than a $0 premium plan because it covered expensive medications better. Always consider your personal medication list and calculate total yearly costs.

6. Alternatives That Count
If you have creditable drug coverage through a union, employer, the VA, or Tricare, you may not need a Part D plan. But make sure your coverage is officially “creditable” to avoid penalties.

7. Avoid the Lifetime Penalty
Skip Part D when you’re first eligible without other creditable coverage, and you’ll face a permanent penalty: 35 cents per month for every month you go without coverage. A one-year delay could cost an extra $4.20/month for life.

8. How Part D Plans Are Structured
Each plan has its own:

• Formulary: List of covered drugs (usually 2,500 to 4,000)
• Tiers: Drug pricing levels from generics to specialty meds
• Deductibles: Up to $590 in 2025
• Out-of-pocket maximum: Capped at $2,000 annually
• Pharmacy networks: Preferred pharmacies offer better prices
• Coverage tools: Quantity limits, prior authorizations, and step therapy

9. Real-Life Example: Generic vs. Brand Name
One client taking four generics (Diltiazem, HCTZ, Lisinopril, Warfarin) found a $0 premium plan that cost only $40 annually. But when switching to a high-cost drug like Eloquis, the $97 premium plan became cheaper overall—saving nearly $500 a year.

10. Get Help Choosing the Right Plan
You don’t have to figure this out alone. Licensed Medicare agents can compare plans across carriers and help you make the best choice for your medications and budget. Their services are free to you. Many also help with enrolling in Social Security or Medicare Part B.

The post Choosing the Right Medicare Part D Plan: What You Need to Know appeared first on ROI TV.

Overview of Medicare Enrollment Trends

Over half of those enrolling in Medicare today are opting for Medicare Advantage plans, highlighting a significant shift in preference among seniors. Despite this, many seniors remain unaware of the critical differences between HMO and PPO networks, which can substantially impact their costs and coverage options.

Original Medicare Structure and Costs

Original Medicare consists of two main parts: Part A (hospital insurance) and Part B (medical insurance). Part A is typically free for 99% of people who have worked for 10 years or 40 quarters and paid into the system. Part B requires a monthly premium, projected to be $185 per month in 2025.

Original Medicare, while comprehensive, has significant gaps, including deductibles, co-pays for extended hospital stays, co-insurance—where Medicare covers only 80%, leaving 20% out-of-pocket—and no cap on out-of-pocket expenses. This leaves many seniors vulnerable to high medical costs.

Options to Fill Gaps in Original Medicare

To address these gaps, seniors can choose between two primary options: Supplemental (Medigap) plans or Medicare Advantage plans. Supplemental plans like Plan G and Plan N provide predictable costs with monthly premiums ranging from $150 to $180, covering most out-of-pocket expenses except the Part B deductible, which is projected to be $257 in 2025.

Medicare Advantage plans, also known as Part C, replace Original Medicare and include drug coverage, but they operate within HMO or PPO networks, each with distinct rules and provider access.

Differences Between HMO and PPO Networks in Medicare Advantage Plans

• HMO (Health Maintenance Organization): Requires members to stay within a strict network of providers. Out-of-network care is generally not covered, except in emergencies. Specialist visits typically require referrals.
• PPO (Preferred Provider Organization): Offers more flexibility, allowing members to see out-of-network providers at a higher cost. Referrals are not required for specialist visits, providing greater freedom of choice.

HMOs often have lower maximum out-of-pocket costs, while PPOs provide greater flexibility and a broader range of provider options, often at a premium.

Common Features of Medicare Advantage Plans

Medicare Advantage plans frequently feature low or $0 monthly premiums, making them appealing for cost-conscious seniors. Drug coverage (Part D) is typically included, eliminating the need for separate drug plans. Additional perks, such as dental, vision, hearing benefits, and wellness programs like Silver Sneakers, are commonly offered.

Supplemental (Medigap) Plans vs. Medicare Advantage Plans

Supplemental plans provide access to any doctor who accepts Original Medicare, roughly 98% of physicians nationwide. They do not require pre-authorizations or referrals, giving seniors and their doctors more control over care. These plans also offer predictable costs with monthly premiums and a single annual deductible.

In contrast, Medicare Advantage plans require prior authorizations for procedures and surgeries, adding extra steps and potential delays in care. They operate on a pay-as-you-go model with co-pays, deductibles, and maximum out-of-pocket limits ranging from $3,000 to $10,000.

Decision-Making Factors for Choosing Between HMO, PPO, and Supplemental Plans

• HMO Plans: Ideal for those who prioritize savings and are comfortable with network restrictions and referrals.
• PPO Plans: Best for individuals who value flexibility and want the option to see out-of-network providers.
• Supplemental Plans: Suitable for frequent travelers or those who want predictable expenses and broader access to doctors without pre-approvals.

Choosing the right Medicare plan depends on your health needs, financial situation, and lifestyle. Evaluating the pros and cons of each type can help you make an informed decision.

The post Understanding the CRITICAL Difference Between Medicare and Advantage PPO’s and HMO’s appeared first on ROI TV.

Deciding When to Retire
Retirement is not just about leaving the workforce; it’s about transitioning from paychecks to relying on your savings, investments, and Social Security for income. The timing of when you claim your Social Security benefits is crucial. Claiming too early can permanently reduce your monthly checks, while delaying can significantly increase your payouts.
The difference is staggering: claiming early can reduce your monthly benefit by as much as $1,200 to $2,000 compared to waiting until full retirement age or beyond. This means the timing of your decision could add up to hundreds of thousands of dollars over your retirement years.

Full Retirement Age (FRA)
Your full retirement age (FRA) is determined by your birth year. For those born between 1943 and 1954, the FRA is 66. If you were born in 1960 or later, your FRA is 67. For those born between 1955 and 1959, the age increases incrementally by two months each year.
Knowing your exact FRA is essential because it marks the point where you can collect 100% of your Social Security benefits. Claiming before this age results in reduced benefits, while waiting longer leads to increased monthly payments.

Social Security Benefit Calculation Formula
Social Security benefits are calculated based on your highest 35 years of earnings, adjusted for inflation. The Social Security Administration uses these figures to determine your Average Indexed Monthly Earnings (AIME), which forms the basis of your Primary Insurance Amount (PIA).
The formula applies “bend points,” which segment your income:

• 90% of the first $1,226 of your AIME
• 32% of the amount between $1,226 and $7,391
• 15% of the amount above $7,391
  This weighted formula ensures that lower-income workers receive a higher percentage of their income in benefits, while higher-income earners receive a smaller percentage.

Impact of Early or Delayed Social Security Claims
The age at which you claim Social Security significantly affects your monthly benefit amount. If you claim before your FRA, your benefits are permanently reduced by about 6% per year, up to 30% if you claim at 62. In contrast, delaying your claim past your FRA increases your benefits by 8% per year until age 70.
For example, if your Primary Insurance Amount (PIA) is $2,311 at your FRA of 66, it drops to $1,670 if you claim at 62 but increases to $2,865 if you wait until 70. That’s a $1,250 monthly difference between the earliest and latest claim ages. This gap can equate to tens of thousands of dollars over your retirement.

Earnings Test for Early Claimants
If you decide to claim benefits before your FRA and continue to work, you’re subject to an earnings test. The annual limit is $23,400, and earning above this amount results in a $1 reduction in benefits for every $2 earned.
The earnings limit increases to $62,160 during the year you reach your FRA, with a $1 reduction for every $3 earned above the threshold. Once you hit your FRA, the earnings test disappears, and you can earn as much as you want without impacting your benefits.

Spousal Considerations and Longevity
If you’re married, the decision of when to claim Social Security is even more impactful. Higher earners can maximize their spouse’s survivor benefits by delaying their own Social Security claim. Upon their death, the surviving spouse is eligible for the higher of the two benefits.
Longevity plays a crucial role in this strategy. If you or your spouse is likely to live into your late 80s or beyond, delaying Social Security can result in significantly higher lifetime earnings.

Examples of Social Security Benefit Scenarios
To illustrate the financial difference that claiming decisions can make, let’s look at a few examples:

• For an AIME of $5,000, the PIA at FRA is $2,311. This reduces to $1,670 at 62 or increases to $2,865 at 70, a monthly difference of $1,250.
• For an AIME of $7,000, the PIA at FRA is $2,951. This reduces to $2,066 at 62 or increases to $3,659 at 70, with a $1,600 difference.
• For an AIME of $10,000, the PIA at FRA is $3,467. This reduces to $2,427 at 62 or increases to $4,299 at 70, resulting in a $1,850 difference.
  These differences are substantial, and over the course of a 20- or 30-year retirement, they add up to hundreds of thousands of dollars.

Key Takeaways and Recommendations
Despite concerns about Social Security’s long-term sustainability, the program is unlikely to disappear. However, changes may be made to keep it solvent, such as raising the retirement age or adjusting benefits.
When deciding when to claim Social Security, consider your financial needs, cash flow, and life expectancy. For those with longer life expectancies or younger spouses, delaying Social Security is often a wise choice, as it maximizes benefits and provides greater financial security for surviving spouses.
The difference in lifetime earnings between claiming early and delaying can be life-changing. Being strategic about your claim decision not only secures your financial future but also provides a stronger financial foundation for your spouse.

Taking the time to understand how Social Security works and how it fits into your overall retirement strategy can be one of the best financial decisions you make. Plan wisely, know your numbers, and choose the timing that best supports your financial goals and lifestyle.

The post Mastering Social Security: Strategies for Maximizing Lifetime Benefits and Spousal Security appeared first on ROI TV.

What Are Chronic Special Needs Plans (CSNPs)?

CSNPs are designed specifically for individuals who have chronic conditions like diabetes, heart disease, kidney problems, or even challenges with daily living. If you have a doctor’s verification, you may be eligible for one of these plans. They come with some unique perks that can make managing health costs a bit easier.

For example, CSNPs often provide:

• Lower costs for durable medical equipment
• Cheaper diabetic testing supplies
• Grocery allowances of around $50 per month

That’s in addition to standard benefits like dental, vision, and hearing coverage, which are similar to what you’d find in a regular Medicare Advantage plan. One of the standout features of CSNPs is the extra election code, which lets you make mid-year plan changes if your situation changes—a major benefit considering most Medicare plans lock you in until the next open enrollment period.

But, and this is important, CSNPs aren’t always the best choice for everyone. It’s crucial to look closely at the plan details to make sure it fits your specific needs.

CSNPs vs. Regular Medicare Advantage Plans

Now, you might be wondering: how do CSNPs compare to regular Medicare Advantage plans? The answer is a bit nuanced.
Both types of plans generally have similar hospitalization costs, co-pays for doctor visits, and out-of-pocket maximums. However, CSNPs sometimes have slightly higher costs. That said, the real difference often comes down to medication costs. For instance, some CSNPs offer $5 co-pays for tier-three drugs, while regular plans might charge a percentage of the medication cost instead.

One thing I always tell people is to be cautious of marketing. Insurance companies and brokers tend to push CSNPs hard because they come with higher subsidies and commissions. That’s not necessarily bad, but it does mean you need to be diligent about making sure it’s right for you—not just right for their sales numbers.

Finding the Right Plan for You

Choosing the right plan is all about understanding your specific needs. Here are a few things I always recommend checking before making a decision:

1. Are your doctors in-network? Some plans limit your choices, which can be a real headache.
2. Ease of use – Does the plan require tons of pre-authorizations or referrals? If so, that could mean extra hassle.
3. Medication coverage – Make sure your prescriptions are covered at a price you can afford.

Also, it’s important to consider whether you want a PPO or HMO plan. HMOs typically require more referrals and pre-authorizations, which can add layers of complexity if you see multiple specialists. In contrast, PPOs offer more flexibility but often come with higher costs.

One crucial tip: avoid plans that replace original Medicare with additional co-pays and red tape. Original Medicare provides predictable costs and broad coverage, which can save you a lot of stress in the long run.

Medicare Essentials Workshop

If you’re still feeling unsure, there’s a great resource called the Medicare Essentials Workshop. It’s a free online workshop that breaks down everything you need to know about Medicare, including common mistakes to avoid. Thousands of people tune in every month, and the feedback has been incredible. If you want to check it out, there’s a link pinned in the comments for easy access.

Co-Pay Protection Plans

One thing that often catches people off guard is the cost of hospitalization. Even with Medicare, the first few days in the hospital can be expensive, and emergency ambulance calls aren’t cheap. That’s where Co-Pay Protection Plans come in. These plans help cover those significant out-of-pocket expenses, providing an extra layer of financial protection. It’s a small investment that can save you thousands in the event of an emergency.

The Value of Trust and Support

Navigating Medicare is not something you want to do alone. I always recommend finding a trusted broker or insurance agent who genuinely puts your best interests first—not just the bottom line. The truth is, your health needs can change. Your financial situation can shift. And when that happens, you need someone you can count on to help you make the right adjustments.

The biggest takeaway from the meeting was this: Be proactive, be informed, and have a support system you trust. Medicare can be a powerful tool for your health and financial security, but only if you know how to use it.

The post Understanding Chronic Special Needs Insurance Plans: Finding the Right Medicare Fit appeared first on ROI TV.

Not All Low Premiums Save You Money

It’s tempting to pick a $0 premium plan, but that could end up costing you more. For example, one plan with a $97 monthly premium might actually save you hundreds over the year if it covers your medications better. That’s why you need to consider the total annual cost—including co-pays, deductibles, and preferred pharmacy pricing—not just the sticker price.

What Does Part D Actually Cover?

Medicare is divided into parts: A covers hospital care, B covers outpatient services, C is Medicare Advantage, and D is for prescription drugs. You can get Part D either as a standalone plan or bundled into a Medicare Advantage plan (MAPD). The right choice depends on your health needs and whether you’re already using a Medigap plan to fill other coverage gaps.

Enrollment Rules You Need to Know

If you’re approaching age 65, your initial enrollment period (IEP) lasts for 7 months—3 months before, the month of, and 3 months after your 65th birthday. But even if you have employer drug coverage, you must enroll in Part D within 63 days after losing that coverage to avoid penalties. You can’t get a MAPD plan unless you’re enrolled in Part B, but for standalone Part D plans, you only need Part A or B.

Can You Switch Plans Later? Absolutely.

You’re not stuck with your first choice forever. Every year, during the annual enrollment period (Oct 15–Dec 7), you can switch your standalone Part D plan. If you’re on a Medicare Advantage plan, you get an additional open enrollment window from Jan 1–Mar 31. Use these periods to update your plan if your medication needs or pharmacy preferences change.

Do You Even Need Part D?

If you have credible prescription coverage through the VA, Tricare, FEHB, or a retiree plan, you may not need Part D at all. But be sure your alternative is “credible coverage” under Medicare’s rules. If it’s not, or if you delay enrolling without coverage, you’ll face a lifelong penalty.

Beware the Late Enrollment Penalty

Skipping Part D because you’re not currently taking medications? That can be a costly mistake. The penalty is around $0.35 per month for each month you delay—forever. Worse, if you develop a serious condition later, you’ll face high drug costs with no safety net.

Understanding Part D Plan Features

Every plan comes with its own drug formulary, which determines which medications are covered and at what cost. Plans usually include between 2,500–4,000 medications and categorize them into tiers. They also use cost-saving tools like quantity limits, prior authorization, and step therapy. Choosing a preferred pharmacy or using mail-order can lead to significant savings. And starting in 2025, your maximum out-of-pocket costs will be capped at $2,000 per year—a huge relief for many.

Real-Life Example: Why Med List Matters

Let’s say you’re taking four generic drugs like Diltiazem, HCTZ, Lisinopril, and Warfarin. A zero-premium plan might cost just $40 per year at a preferred pharmacy. But if your doctor switches you to a costly drug like Eloquis, suddenly that zero-premium plan could cost over $1,600 annually. In contrast, a $97/month plan might now be cheaper overall. Your medication list matters more than your monthly premium.

Choosing the right Medicare Part D plan can save you hundreds—sometimes thousands—of dollars per year. Don’t go it alone, and don’t guess. Make sure your plan fits your medications, pharmacy, and budget so you can spend your retirement enjoying life—not stressing over prescriptions.

The post How to Choose the Right Medicare Part D Plan (and Avoid Costly Mistakes) appeared first on ROI TV.

Let’s simplify things. In this article, we’ll break down what Medicare Parts A and B actually cover, how premiums are calculated, and why many people choose to add a supplemental insurance plan like Plan G or Plan N.

Medicare Part A vs. Part B: What’s the Difference?

Medicare is divided into multiple parts. Here’s a quick breakdown:

• Part A covers inpatient hospital care, skilled nursing facility care, hospice, and some home health services.
• Part B covers outpatient services—everything from doctor visits and preventive care to outpatient surgeries, diagnostic testing (like MRIs), durable medical equipment, and even some home health care.

Think of Part A as hospital insurance, and Part B as medical insurance for anything that doesn’t require an overnight stay.

How Do You Qualify for Medicare?

You’re eligible for Medicare if you’ve worked and paid FICA or SECA taxes for at least 40 quarters (10 years). These payroll taxes—1.45% of your income, matched by your employer—fund the Medicare system. There’s no income cap, so even high earners pay in.

If you didn’t reach 40 quarters, you can still get Medicare Part A by paying a premium:

• $285/month if you worked 30–39 quarters
• $515/month if you worked less than 30 quarters

Part B is available to all Medicare-eligible individuals and carries a monthly premium, regardless of work history.

How Much Does Medicare Part B Cost in 2025?

The standard Part B premium in 2025 is $185/month, but this number can go up if your income is higher.

The amount you pay is based on your Modified Adjusted Gross Income (MAGI) from your tax return. It includes:

• Line 11: your total adjusted gross income
• Line 2a: your tax-exempt interest income

Here are the basics:

• Single filer earning under $106,000 or married couple earning under $212,000: standard premium
• Above those thresholds? You’ll pay an IRMAA surcharge (Income-Related Monthly Adjustment Amount), which increases your premium across five tiers

These thresholds are updated annually, and your premium may go up or down depending on changes in your income.

When Should You Enroll in Medicare?

There are three main enrollment windows:

• Initial Enrollment Period (IEP): The 7-month window around your 65th birthday
• Special Enrollment Period (SEP): If you delayed enrollment because you were covered by a large employer group health plan (20+ employees)
• General Enrollment Period (GEP): January 1 – March 31 each year for those who missed their IEP or SEP (this option may come with penalties)

If you’re receiving Social Security at 65, you’ll be enrolled automatically in Parts A and B. But if you’re still working and covered by employer insurance, you may want to opt out of Part B to avoid paying unnecessary premiums.

How Medigap Plans Work and Why They Matter

Medicare doesn’t cover everything. There are significant gaps, including:

• A $1,676 deductible per hospital stay under Part A
• Daily hospital co-pays starting in the third month
• $257 annual deductible for Part B
• 20% coinsurance for most outpatient services
• Up to 15% in excess charges if your doctor doesn’t accept Medicare assignment

That’s where Medigap policies come in. These are supplemental insurance plans designed to cover those gaps.

You can buy a Medigap plan during a six-month Open Enrollment Period, which starts the month your Part B coverage begins. During this time, you can get coverage without any medical underwriting—meaning you can’t be denied based on preexisting conditions.

What’s the Difference Between Plan G and Plan N?

Two of the most popular Medigap plans are Plan G and Plan N.

• Plan G: Covers everything Medicare doesn’t—except the $257 Part B deductible. It’s the most comprehensive coverage available to new enrollees.
• Plan N: Covers nearly everything that Plan G does, but with a few small differences:
  • $20 copay for doctor visits
  • $50 copay for ER visits (waived if admitted)
  • No coverage for excess charges (those up-to-15% add-ons from some doctors)

Plan N generally has lower premiums, making it a good fit for people who are healthy and don’t mind a little cost-sharing.

Out-of-Pocket Costs Add Up Fast Without a Medigap Plan

Without a supplemental plan, you could face thousands in unexpected bills:

• Extended hospital stays can cost $419 to $838 per day after the first 60 days
• Skilled nursing facilities charge $250 per day after 20 days
• All outpatient services require you to pay 20% of the cost

A Medigap policy can protect you from these bills and give you predictable costs in retirement.

Special Situations to Be Aware Of

• Already enrolled automatically in Part B? If you’re still working and have a good employer plan, you can opt out of Part B to avoid paying duplicate premiums.
• Still contributing to an HSA? You’ll want to delay all Medicare enrollment, including Part A, because once enrolled, you can’t contribute to your HSA anymore.
• Employer coverage not so great? You can transition to Medicare at 65—even if you’re still working. Employers are required to accommodate this switch.

Which Plan Should You Choose?

Choosing between Plan G and Plan N comes down to this:

• Plan G is for those who want simplicity and full coverage
• Plan N is for those who want to save a little money and don’t mind a few copays

Either way, you’ll be far better protected than with Medicare alone.

The post Understanding Medicare Parts A and B: What’s Covered, What’s Not, and How to Fill the Gaps appeared first on ROI TV.

These services are essential to staying healthy and independent, especially in retirement. Let’s walk through what Medicare covers, where it falls short, and how you can fill those gaps affordably.

What Medicare Covers—and What It Doesn’t

Let’s start with the basics. Original Medicare (Parts A and B) does not cover routine dental care, glasses or contacts, or hearing aids. These are considered “non-medical” services, even though we all know they’re essential.

Dental Care: Cleanings, fillings, extractions, and dentures? Not covered. Medicare only steps in when dental services are medically necessary and tied to something more serious—like prepping for heart surgery or treating jaw cancer.

Some examples of what is covered:

• Tooth extraction before chemotherapy
• Dental exam before a heart valve replacement
• Treatment linked to oral cancer or jaw reconstruction

Vision Care: Medicare does provide decent coverage for medical conditions like:

• Cataracts (including surgery and one set of post-surgical glasses)
• Glaucoma testing
• Macular degeneration treatments
• Diabetic retinopathy screenings

But routine eye exams, glasses, and contacts? Not unless they’re tied to a medical procedure like cataract surgery.

Three Medicare Path Options—and Their Perks and Pitfalls

When it comes to how you get your Medicare, there are three general paths:

1. Original Medicare only – This is the riskiest choice. About 10% of people go this route, but it leaves you exposed to unlimited financial liability.
2. Original Medicare + Supplemental Plan (like Plan G or Plan N) – This combo gives you great coverage for medical care, but you still need separate plans for dental and vision.
3. Medicare Advantage (Part C) – These are bundled plans managed by private insurance companies. About 50% of Medicare beneficiaries go this route. Many Advantage plans include dental, vision, and hearing extras, though the quality and limits of those perks vary widely.

Filling the Dental Coverage Gap

Since Medicare doesn’t cover regular dental care, many people buy a standalone dental plan.

Here’s what to expect:

• Monthly premiums: $30–$80 depending on coverage
• Annual benefit limits: $1,500–$5,000 per year
• Coverage tiers:
  • Preventive care (cleanings, exams): 100% covered immediately
  • Basic care (fillings, simple extractions): 80–90% after a 6-month wait
  • Major care (crowns, root canals, dentures): 50% after 12 months

To avoid waiting periods, the best time to sign up is within 30–60 days of losing group coverage. Plans often waive those waits if you’re coming off an employer policy.

Adding Vision Coverage to Your Plan

Standalone vision plans are affordable and easy to bundle with dental coverage.

• Monthly premiums: $12–$18
• Annual benefits: About $300 for glasses or contacts
• Included perks:
  • One annual eye exam at no cost
  • Discounts on frames and lenses
  • Large networks like EyeMed and VSP

Just like dental, it’s smart to enroll when you leave a group health plan or when you’re signing up for a dental policy.

Medicare Advantage: Bundled Coverage with Perks—But with Trade-Offs

Medicare Advantage plans, managed by private insurers, often include built-in dental and vision coverage—or let you add optional “riders” to extend those benefits.

Dental benefits can include:

• $1,000–$2,000 annual allowances
• Full coverage for cleanings and exams
• 50% coinsurance for out-of-network services
• Optional dental riders (e.g., $54/month for $1,500 in benefits)

Vision benefits often include:

• One routine eye exam per year (zero copay)
• $100–$300 annual eyewear allowances
• Some reimbursement for out-of-network eyewear purchases

But remember: Advantage plans come with networks. If your preferred dentist or eye doctor isn’t in-network, you could end up paying more—or not be covered at all. Also, not all Advantage plans are created equal, so it’s important to read the fine print.

What About Hearing Aids?

While this outline didn’t focus heavily on hearing coverage, it’s worth noting that Original Medicare doesn’t cover hearing exams or hearing aids either. However, many Medicare Advantage plans include some level of hearing aid benefits, often through partner networks.

Final Thoughts: Making the Right Move for Your Needs

If dental, vision, and hearing are important to you—and let’s be honest, they are—then make sure you’re not relying on Original Medicare alone.

Here’s what you can do:

• Add standalone dental and vision plans to your supplemental Medicare coverage
• Compare Advantage plans if you want bundled extras, but check the provider networks and coverage limits
• Sign up early, especially when leaving group insurance, to avoid waiting periods and penalties

Our team at Medicare School is here to help walk you through your options. With the right plan in place, you’ll have peace of mind—not just for your health, but for your wallet, too.

The post What Medicare Really Covers for Dental, Vision, and Hearing appeared first on ROI TV.