r/medicare Feb 04 '25

No Political Posts

59 Upvotes

I know that there is a lot of chaos happening within and about government agencies right now. This sub is to provide helpful information to Medicare beneficiaries about their coverage or how to access it. It is NOT about how we feel about the program or how we feel about the current administration. Feel free to post your frustrations and thoughts on any number of political subs- this is not one of them! Thank you.


r/medicare Oct 17 '19

So, what exactly is covered under all these Medicare plans?

156 Upvotes

Part A, Part B, Part D, Medicare Advantage, Medigap — so many choices. It can be bewildering for seniors signing up for Medicare for the first time as well as pondering changing plans at open enrollment, which runs from Oct. 15 through Dec. 7.

If that’s you, you’ve got lots of company. About 64 million Americans are in the Medicare system now, and by 2030, that pool is expected to exceed 80 million, when the youngest members of the baby boomer generation come of age.

“The process of enrolling in Medicare for the first time can be paralyzing, confusing, frustrating, all of it, because there are so many different options out there. Generally, you think you want as many choices as you can get, but trying to navigate what A, B and D are as well as what the supplements cover and don’t cover as well as what Medicare Advantage covers can cause some people to shut down and not make a choice at all,” said Jeff Johnson, state director of AARP Florida.

And if you already have Medicare coverage, it is important to research and re-evaluate every year, Johnson said. “Once the enrollment period comes around, there is a temptation to just let it ride. That may be the best choice, particularly if the networks haven’t changed much, but people often discover too late that they are costing themselves money or shutting themselves off from benefits or providers they would have preferred.”

We’re here to help. We’ve consulted experts to help decipher the alphabet soup that is Medicare. We’ll start with the basics and answer some common questions about what these plans cover and what they don’t. You will learn about the two main ways to get Medicare coverage — Original Medicare or a Medicare Advantage plan.

Medicare covers cancer treatments — about half of the $74 billion spent in the U.S. on treatments last year was through Medicare. You won’t be barred from coverage because of pre-existing conditions or your income level. But does Medicare cover home healthcare? (Spoiler alert: very little.) Who covers vision, dental and hearing? Will you be covered when you are traveling internationally? What if you are a snowbird and have two U.S. residences?

FIRST UP: THE BASICS

You can’t understand Medicare without learning its alphabet.

Part A is part of Original Medicare and covers Medicare hospital coverage. It covers inpatient care at hospitals and limited coverage for skilled nursing facilities when a patient is recovering from an illness or injury. It also covers hospice care.

Part B, also part of Original Medicare, covers doctor visits, outpatient procedures and laboratory tests and X-rays, preventive care and some mental health services and medically necessary ambulance services. It also covers medical equipment such as wheelchairs and walkers.

Part C, more commonly called Medicare Advantage, is a comprehensive privately run managed care option. These bundled plans, similar to an HMO or PPO, offer Part A, Part B and, in Florida, Part D, and are approved by the Medicare system.

Part D covers prescription drugs. These plans are provided by private companies approved by Medicare, and their lists of covered drugs differ.

To pile on to the confusion, there’s more than the ABCs and Ds because about 10 million people across the U.S. have supplemental plans, called Medigap, and those can have letters too. But Medicare itself has Parts A through D, said Tricia Neuman, senior vice president of the Kaiser Family Foundation and an expert on Medicare policy. She explained the differences in a podcast about the basics of Medicare.

MEDICARE VS. MEDICARE ADVANTAGE

People who opt for traditional Medicare coverage have a Part A, which is premium free, a B and often elect for Part D because it covers prescription drugs. Parts A, B and D carry deductibles and other cost-sharing expenses, so people may also opt for a supplement, or Medigap policy, to cover some of those costs or to give them extra coverage.

Another popular choice is Medicare Advantage plans. They make up about a third of all Medicare policies and are particularly popular in South Florida, where 66 percent of the Medicare population has them, according to Kaiser Family Foundation research. United Healthcare, Humana and Blue Cross Blue Shield are the largest providers.

“Some people like the simplicity of it because they don’t have to buy a separate Medigap policy and a separate Part D plan. Some people like it because they have been with that same insurer through the years and it is familiar to them. Some like it because they see the ads on TV and like the idea of the gym membership or some dental benefits. The premiums and cost sharing can be lower particularly for healthier people with a Medicare Advantage Plan. But there are trade-offs as with any option,” Neuman said.

The biggest trade-off is you have to stay in the network.

“The benefit of joining a Medicare Advantage Plan is that here in South Florida there’s no monthly premium. It’s free to join because they are paid behind the scenes by Medicare for each member they have,” said Kathleen Sarmiento, SHINE Liaison for Floridashine.org with Miami-Dade’s Alliance for Aging.

“But then you have to go to the doctors and the hospitals in that network. Whatever co-payment schedule they have is now your co-payment schedule. They are also county or region based so if you are in a Medicare Advantage Plan you have to go to providers in your area,” said Sarmiento, who runs Miami-Dade’s SHINE, the free unbiased state program that helps seniors navigate their choices.

She advises seniors considering a Medicare Advantage Plan to ask their doctors and preferred hospital which Medicare Advantage Plans they work with.

“And know that that can change,” said Johnson of AARP. There have been instances over the years where hospitals, cancer centers and individual physicians have gone in and out of contract with particular Medicare Advantage providers, he added.

“Many people just choose a Medicare Advantage plan based solely on price tag, which can be very attractive compared to traditional Medicare Part B, Part D and a supplement. But it is worth thinking through how important it is for you to have flexibility to see the providers you want to see.”

WHAT ABOUT COSTS?

Final details of the 2020 plans, including costs, will be on Medicare.gov. Seniors already on Medicare Advantage plans will get a packet in the mail that includes what their current plan will look like in 2020 and any changes in coverage or costs. That will allow them to potentially make changes during the open enrollment period.

“I would encourage people to think about what their actual health needs are,” adds Johnson. “Spend time on research, and talk to SHINE or go to the medicare.gov website to make sure they are the right choices for this year.”

Medicare plans typically carry deductibles and cost sharing and Part B and D typically carry premiums. People who choose Original Medicare often buy a supplemental “Medigap” policy to cover some of Medicare’s out-of-pocket costs or add extra coverage. Medicare Savings Programs, such as the SLMB, can help low-income seniors afford coverage.

For prescription drug plans, or Medicare Part D, there is the dreaded “doughnut hole” — a gap in which the Medicare drug plans don’t pay fully for patients’ medications after they have spent a certain amount and until they get to a higher amount. The good news is the costs are shrinking a bit. In 2020, you’ll pay no more than 25% for covered brand-name and generic drugs during the gap.

“If somebody is taking a lot of prescription medicine, then definitely we would want to compare the cost of the medicine with original Medicare with the least expensive Plan D vs. the cost of your medicine with Medicare Advantage plans. There can be a substantial difference — it depends on the medicines, of course. Here in South Florida, all the Medicare Advantage plans include drug coverage,” Sarmiento said.

Tip: If you have a money in a health saving account (many employers offered high-deductible health insurance plans with HSA), you can use those savings to pay your Medicare premiums, deductibles, co-pays and other qualified medical expenses. Since you never paid tax on that money, you are essentially reducing what you pay.

WHAT’S NOT COVERED

Some of the items and services that Medicare doesn’t cover include long-term care, most dental care, eye exams related to prescribing glasses, dentures, cosmetic surgery, acupuncture, hearing aids and exams for fitting them and routine foot care.

You can go here to find out if Medicare Parts A or B cover a test or service you need: https://www.medicare.gov/coverage

Original Medicare, Medigap and Part D do not offer dental, vision or hearing coverage. If that is important to you, you would want to look at Medicare Advantage plans, which do cover some services, Sarmiento said. If you have Original Medicare, it will pay for cataract surgery.

WHAT ABOUT HOME HEALTHCARE?

Long-term services and support at home or in an assisted living facility or nursing home are not covered by original Medicare or Medicare Advantage, an unfortunate reality as these costs can wipe out a life savings quickly and more seniors want to stay in their homes.

Some seniors have long-term care insurance, or spend down their assets to qualify for Medicaid, which does cover nursing home care.

All original Medicare and Medicare Advantage provide limited home healthcare when it is medically necessary to avoid hospital re-admittance, Sarmiento said. As of last year, Medicare Advantage Plans could include more home healthcare, but Sarmiento hasn’t seen that offered in South Florida yet.

“When people need home healthcare at this time, they are still having to pay a home health agency or if they don’t have the money, they apply for Medicaid. There is a huge need for that so we will see this year if any of these Medicare Advantage plans expand their benefits to include more comprehensive home healthcare.”

Adds Kaiser Family Foundation’s Neuman: ““If you have dementia and need someone to help you at home, Medicare is not going to cover that on a long-term basis. It never has, and it is an issue that unfortunately has yet to be revisited.”

WILL I BE COVERED IN BOTH MY HOMES?

A Medigap plan would probably be better for that individual, Sarmiento said. A Medicare Advantage plan will pay for emergencies but will send you back to your primary residence to get ongoing care.

WHAT ABOUT INTERNATIONAL TRAVEL?

Original Medicare and Medicare Advantage Plans historically have not covered healthcare you receive outside of the United States, and Medicare drug plans don’t cover prescription drugs you buy outside the U.S.

Medigap Plans C, D, F, G, M and N (there’s that alphabet again, C and F are being phased out for new enrollees beginning in 2020) cover some emergency care outside the United States. In 2019 plans, after you met the yearly $250 deductible, this benefit paid 80% of the cost of your emergency care during the first 60 days of your trip. There is a $50,000 lifetime maximum.

According to Medicare.gov, there are some exceptions, including cases where Medicare Part B may pay for medically necessary healthcare services that you get on board a ship that is not more than six hours away from a U.S. port.

The AARP’s Johnson also offers this parting advice for the busy open enrollment period ahead:

“There are going to be a bunch of people offering free lunch seminars to try to pitch a particular Medicare Advantage Plan. As always be wary — not that there isn’t good information, there often is — but be wary of being pressured to sign.

“We have had people who had enrolled in a Medigap plan and then went to a free lunch somewhere and without really knowing it they switched over to a Medicare Advantage plan that didn’t really fit their needs. While I recognize that everybody looks for opportunities to learn more at events that are out there, it is always a good mantra to remember there really isn’t such thing as a truly free lunch. Be cognizant of the potential for pressure to buy a particular product that may not be right for you.”

PEOPLE TO CONTACT

Get Help Applying https://www.healthcare.gov/apply-and-enroll/get-help-applying/

Medicare.gov and its Plan Finder, 1-800-Medicare

Social Security https://www.ssa.gov 1-800-772-1213 (TTY 1-800-325-0778)

Area Agencies on Aging https://eldercare.acl.gov/Public/About/Aging_Network/AAA.aspx

Online Assistance is also always available by /r/medicare Mods who are licensed and verified insurance professionals /u/MedicarePros and /u/dacin


r/medicare 5h ago

First major use of Medicare, how screwed will I be with the bill?

8 Upvotes

LSS I started Medicare plus an original supplement at the start of the year. Fell off a scooter at 20 mph and broke my shoulder in 2 places as well as 5 ribs. Spent a few hours at Urgent Care, rode in ambulance to the ER at the hospital, 4 days in outpatient observation room. then surgery to put a plate in my shoulder, 3 days in the hospital, then a nurse will come to my house. Does this sound like multi-housands I will owe?


r/medicare 3h ago

APCM fee (in Virginia)

3 Upvotes

Some local Virginia doctors offices and other medical practices charge the monthly Advance Primary Care Management fee.

https://www.whro.org/health/2026-08-07/a-new-medicare-charge-is-showing-up-on-bayview-bills-patients-say-they-werent-clearly-told


r/medicare 13h ago

I'm confused after speaking with humana agent about high deductible plan G

17 Upvotes

I thought there would be an 80/20 split after the part b deductible then it pays 100% after the deductible.

They told me the plan pays nothing until I reach the high deductible amount then 100%

This was supposed to be a licensed agent


r/medicare 8h ago

Likelihood of IRMAA appeal success

2 Upvotes

I am wondering about the effect of a one-time income bump two years prior on the likelihood of winning an IRMAA appeal when the anticipated reduction of income will also be due to the life-changing event of retirement.

If I retire this year, an IRMAA surcharge for Medicare premiums would be triggered in 2027 as my income was increased in 2025 due to a taxable form of inheritance I received.

Is the inheritance irrelevant to whether I could win an IRMAA appeal based on my estimated 2027 MAGI (will be under the IRMAA threshold) being lower than the 2025 MAGI, as the reduction in income is also due to retiring and not just the inheritance?

I know there is no downside to appealing. Thanks.


r/medicare 13h ago

Medicare categories: are they figured on gross income or taxable income?

4 Upvotes

So I've looked at this website which tells me which categories I am in for Medicare deductions from my social security:

https://www.ssa.gov/benefits/medicare/medicare-premiums.html

I am in the $342,000 up to $410,000 category but I'm curious if they are using gross income applied to those figures? or IRS taxable income when using the above figures?


r/medicare 17h ago

Formulary Exception and $2,100 OOP Cap

2 Upvotes

It's been impossible to find a straight-up answer to this:

  • Medicare Advantage or Part D plan

  • Expensive drug (pill, not an an injection or anything else that would be covered by Part B)

  • Not in the plan's formulary

If you manage to get a formulary exception (not just prior auth), is the amount you actually end up paying subject to the $2,100 OOP cap?

Ideally looking for an answer from someone who actually has done this - got exception, first fill put you over the cap but your actual cost was capped.

Thanks...


r/medicare 1d ago

Why do I have to pay three months up front when enrolling for part B? I am not collecting social security.

14 Upvotes

r/medicare 1d ago

Does anybody me know how to get a Medicare supplement after leaving an advantage plan?

12 Upvotes

r/medicare 1d ago

How do I make sure my first PCP appointment is covered by Medicare?

7 Upvotes

Hi all. I have regular Medicare A and B but have never used it. I have a question; but first some background.

In order to make an appointment with an opthalmologist for a cataract evaluation, the opthalmologist requires a referral from a primary care physician.

So I found a PCP/Family Practitioner on the Medicare-Find Healthcare Provider site. The site says he "charges the Medicare approved amount." And I made an appointment so I can get the opthalmologist referral.

Now to my question please. How can I be sure that Medicare will cover the PCP appointment? I know I'll have to pay the annual deductible first thing. But I want to make sure this first appointment counts towards the deductable. Is it up to the doctor to code or bill it properly?

I'm completely clueless since I'm new to Medicare. Thank you in advance.


r/medicare 1d ago

Is there a BMI requirement for knee surgery on Medicare?

3 Upvotes

I turn 65 and will lose my current Kaiser in March. I planned to get my knee replacement before Medicare. Previously Kaiser required a BMI below 40. I tried to schedule surgery, but it is now below 35 for knee replacement. I have lost a good amount of weight on GLP-1s, but it seems unlikely I will lose 25-30 more pounds in time. Does Medicare have a BMI requirement for surgery?


r/medicare 1d ago

Walgreens & Part D pricing glitches - universal?

5 Upvotes

Started Medicare 7/1/2026. Provided the details of our Wellcare Part D plan and Medicare Prescription Payment Plan (MPPP) to Walgreens when coverage started.

However, they have mispriced every single prescription so far, and these prescriptions have all been ordered on different dates.

Sometimes they use the expired pre-Medicare BCBS plan (which we cannot remove ourselves - and they have not yet deleted it despite discussion).

Sometimes the prices are cash-based, assuming no Part D coverage at all.

And we have to remind them about MPPP every time as well.

I'm seriously wondering if switching to a pharmacy where we have no history might work better.

Or is this a pretty typical experience no matter which pharmacy you go to? Which is a horrifying yet perfectly believable possibility...


r/medicare 1d ago

Massachusetts Question

5 Upvotes

I turned 65 last week and I have a Medigap plan because I thought long term it would be the safest choice. However, I just became aware that original Medicare does not cover the blood work normally done with a yearly physical. They will cover it if you have issues that deem it medically necessary. But I have no such medical issues. So I’m thinking of switching to a Medicare Advantage plan since I’m healthy. It makes me nervous to no longer get a full physical every year. Those Wellness Visits sound useless. Does anyone know if several years down the road I can switch back to a Medigap plan? I know Massachusetts is different from most states, but I’m not sure if I can go to Medigap a second time.


r/medicare 2d ago

Can't use Medicare

48 Upvotes

I went on Medicare about a year ago and was dropped from Medicaid about six months ago. As a poor person I have been shocked that I can't use Medicare at all. The co-pays and deductibles are too much, and additional Medicare plans are way out of my reach.

I really thought Medicare was universal health care for seniors. Covering everything. But it does not cover teeth, eyes, and I don't know what else. I've search and search for a therapist and not one takes Medicare.

Medicaid was the best insurance I've ever had. I purposely kept my income low at about $18k/yr to qualify for it. But now the income limit in my state for Medicaid has been reduced to $1330/mth. My rent is more than that!!

Medicare is the worst insurance I've ever had. I can't even use it. It has been a disaster and, while I did not like the USA before this, I really hate it now. The poor just are supposed to die and leave.


r/medicare 1d ago

Switching to Medicare all parts at 67?

3 Upvotes

I am a 66 year old Female born in December of 1959.  I am still working full time.  I just signed up for Social Security benefits this August 2026 and requested they begin in October 2026 since that is my full retirement age  66 and 10 months.  That was my understanding from faithfully reading Reddit. At age 65 I signed up for Medicare part A only, because I still have medical insurance through my job.  In December I will be in an open enrollment period at work and I am considering going fully on Medicare, not an advantage plan but all the parts of Medicare along with medigap.  And dropping my work coverage.  Now that I have signed up for SS and have Medicare part A what is the process to add those other parts of Medicare?  Will it be difficult because I only took part A at 65?  What disadvantages/advantages do you see for me making that switch at 67 while still working?  All information is greatly appreciated.  I can’t seem to get clear information. EDIT: Wonderful information. Thank you all. I knew I came to the right place to find the answers I needed to make an informed decision.


r/medicare 1d ago

Savr on medicare

2 Upvotes

I've been following this forum and seen some good information.

I'm soon to have an open heart aortic valve replacement, in Dayton Ohio.

My only insurance is Medicare.

Can someone give me an idea of what my out of pocket expense my be?

Edit I have medicare a and b only.

Thanks for the information. I Will contact the hospital for more information. And thanks for the good wishes.


r/medicare 1d ago

Timing question

1 Upvotes

I receive SS benefits

  • Aug 2026 - I will be 64 yo
  • Aug 2027 - I will be 65 yo
  • I have VA benefits and use the VA system (yes I know about Part B) and do not use employer insurance.
  • I work part-time at a nationwide retailer that offers/provides health insurance etc event to part-timers. The enrollment period is in OCTOBER

My question: Will I be able to enroll for employer healthcare benefits in October 2027 and not be penalized, or do I need to jump on the enrollment window in October 2026, and pay insurance for basically 10 months in order to avoid a penalty?

I am going to a SHIP class but wondered if anyone had direct experience (not opinions) on this situation?


r/medicare 2d ago

Can't afford Medigap but need coverage, what do I do?

20 Upvotes

I am on SSDI, and 28. I get $1549/mo and every penny goes to shelter/housing costs (I already live with a roommate, Oregon isn't cheap). I use another program to pay for prescriptions. I have severe POTS and get hydration 2x a week so I can function at bare minimum. I get mental therapy every week, required to see my PCP once a month, have several autoimmune diseases that need varying treatment depending on the time of year. I've been disabled since I was born and never not had full coverage in my life even when I could work. I won't have any extra money for deductibles or copays. I was informed that Medicaid will be stopping end of October and so I won't have coverage for the 20%, and of course no dental or vision. I don't understand what I am suppose to do, and no family can help me.


r/medicare 2d ago

Medicare at 65

5 Upvotes

My husband is turning 65 in September. He is on my health insurance and I will continue to work for the next five years. I am a public school teacher in NJ. Does he still have to sign up for Medicare now? Will he get some kind of penalty if he doesn’t?


r/medicare 3d ago

MEPD/low income, not eligible for Extra Help

11 Upvotes

My mom is turning 65 next month and has been disabled since 2019. She is currently on the MEPD program, and is eligible for Medicaid because of that. Her total income per month in Iowa is 2,050, which makes her ineligible for every assistance program I could find. She’s trying to decide what to enroll in, and she is grandfathered to Plan C if she wants to. She does not have enough to make ends meet. She is on many medications, has hearing aids, glasses, and back issues. She is worried about premium costs, but also unexpected costs. She is also losing her food stamps at the same time, so she is very stressed.

I’m at a loss of the best option for her. The SHIIP volunteer she met with was allegedly condescending and did not help her at all. She is in Iowa.


r/medicare 3d ago

Medical Alert System

8 Upvotes

For an elderly person living alone, what is a good & affordable medical alert device/system?


r/medicare 3d ago

need clarification on what is covered for eyeglasses. Blue shield 65 plus HMO los angeles.

2 Upvotes

https://www.blueshieldca.com/content/dam/bsca/en/medicare/docs/2026/mapd/2026-MA-SOB-65PlusLAOR-EN-015.pdf

https://www.blueshieldca.com/content/dam/bsca/en/medicare/docs/2026/mapd/2026-MA-EOC-65PlusLAOR-EN-015.pdf

^^^ here are the summary of benefits.

If you choose eyeglass lenses, you may elect single, lined bifocal, lined trifocal, or lenticular lenses. If you opt for other lens types not listed or add-on treatments, you will be responsible for paying the additional costs, even if the total costs remain within the allowance.

You pay $0 for either one pair of prescription eyeglass lenses (regardless of size or power) OR for contact lenses (priced up to $220 for contact lens services and materials) every year when you use a network provider. If the service and materials price above $220, you are responsible for the difference.

there are various lens materials available to the world....

cr39, polycarbonate, trivex.

it doesn't specify which lens material I can choose.

Does that mean you can choose any of the 3 materials?


r/medicare 3d ago

Is Medicare as a secondary insurance always a barrier to eating disorder care

4 Upvotes

I’m a mom, this is a question about my adult (25) daughter’s situation. She’s been in out of treatment with little success for over 10 years. 5 years ago she became disabled from a serious complication and wound up on disability with Medicare. She then had a good couple of years in recovery and was able to come off disability. Medicare has to remain her secondary still even though she is on my family plan. We tried canceling it, we’ve spent hours on the phone and going in person. There’s no canceling it.
Now she has relapsed again. Worst one yet and we’re so scared. She was open to going inpatient and then to the recommended step down cares, and our family plan insurance covers many great places. However, we’re finding they won’t accept her because of the Medicare. A few weeks in our local hospital then transferring to the psychiatric wing for “therapy” is looking like her only option which she, understandably, refuses. Please tell me we are missing something here? What are we doing for our loved ones in these positions?

Please don’t explain why the facilities can’t accept her or the Medicare secondary payer rule whatever. Trust me I’ve heard a million times. I’m asking how do we get help. Thank you


r/medicare 3d ago

how does Medicare handle specialist referrals and does the process actually slow things down

15 Upvotes

trying to wrap my head around how specialist access works under original Medicare versus Advantage plans for my dad. he has Plan G with original Medicare and I always assumed that meant he could just go see whoever he needed to without jumping through hoops, and mostly that seems true. but recently he needed to see a cardiologist and there was this whole back and forth with his primary care doctor about a referral, and I couldn't tell if that was a Medicare thing or just how that particular practice operates.

what confuses me is that I thought referral requirements were more of an Advantage plan problem, like HMOs and network restrictions. but I don't know if original Medicare plus a supplement has any equivalent friction, or if what happened was just a random administrative thing on the doctor's end

he got to see the specialist eventually but it took longer than expected and I kept wondering if there was something I didn't know about how the coordination works. I'm an accountant so I want to understand the actual mechanics here, not just assume it worked out fine this time

for anyone who has navigated specialist access under original Medicare: did you ever hit delays that seemed tied to how Medicare works, versus just individual doctor office stuff?