Faq – Mike Medicare Matchmaker

Frequently Asked Questions

Connect with Mike – The Medicare Matchmaker for clear, personalized guidance. Get answers to your questions, explore your coverage options, and move forward at your own pace without pressure.

What are the reasons why I should work with a Medicare agent?

You should ensure you have a clear strategy for what you are trying to achieve with Medicare, and a crystal-clear process for how you’ll execute it. There are so many Medicare plan options, and there are so many variables to consider & compare when aligning and/or reevaluating your strategy. A good broker will perform these functions on your behalf at no cost to you. Why not use a good broker?

What's the difference between a Medicare broker and a Medicare agent?

A Medicare agent is under contract with a single health insurer, while a Medicare broker is contracted with multiple health insurers.

What's the most cost-effective way for a healthy 65-year-old to structure their Medicare coverage?

There isn’t a single answer to this question. If I’m asked this question, I would discuss a framework with my client to form a response. The first part of the framework would be related to low, medium, or high annual healthcare utilization. The second part of the framework relates to their financial income status, using low, medium, or high income. Finally, I’d layer in their response as to their preference for how they prefer to pay for their healthcare. They can choose between financing to “fix and forget it,” meaning they insure themselves so they don’t worry about individual health care transactions & claims, or they can choose “pay as you go,” whereby they pay premiums, deductibles, coinsurance & copayments as they occur.

Putting this framework to work is a logical methodology for finding which Medicare option is the most “cost-effective” for an individual.

Isn't Medicare headed for a crisis with so many baby boomers aging into the system?

Crisis is a reasonable word. Not only are more people aging in but the number of claims as well as the cost of those claims is outpacing the current rate of government reimbursement. No easy fixes and of course, unfortunately, it is a major political issue!

I'm on an expensive specialty medication. Will the 2025 Part D changes help someone in my situation?

2025 Changes did help people on expensive specialty medications, largely due to the elimination of the “donut hole”. After you paid $2000 out-of-pocket, you no longer had to pay for your medication. 2026 is going to be a little more difficult. Many plans have added a $500-$615 deductible for medications while also raising coinsurance amounts for medications falling into Tiers 3-5. Finally, you need to reach $2100 in the “initial” phase in out- of-pocket before you no longer pay. The net result is that you’ll spend more in 2026 than in 2025, and that will likely be in the $2700+ range.

Does Medicare cover hearing aids, or do I have to pay out of pocket?

Medicare does not cover hearing aids; however, Medicare Advantage Plans often offer a hearing aid benefit as part of an extra benefits package. Benefits vary by plan, and you’ll likely have a co-payment and perhaps a limit, but given the cost of hearing aids, it certainly helps!

Am I responsible for an IRMAA surcharge?

The short answer is yes, you are. Since the IRMAA surcharge is based upon past earned wages, if your current financial situation has changed and you are now lower or below the IRMAA income brackets, you can contact Social Security for an adjustment.

Do I qualify for SEP if my health dramatically gets worse out of nowhere?

Certain qualifying conditions may make you eligible for a Chronic Care Special Needs Plan(CSNP). If there is a plan in your service and you’ve been newly diagnosed with a qualifying condition, you would likely be eligible for SEP enrollment.

I've had the same Part D plan for years, but this year my insulin shot up in price. Did the Inflation Reduction Act not fix this yet?

You have likely experienced a deductible added to most plans this year. The deductible may be as high as $615, meaning you have to pay cash for your medications, including your insulin, until you reach the deductible. Once you reach the deductible, your insulin co-pay will be no more than $35 per the Inflation Reduction Act.

I have severe rheumatoid arthritis and my biologic medication costs $6,000 per month. How will the 2025 Medicare Part D changes affect someone in my situation?

If you are not receiving any assistance directly from the manufacturer of your biologic, you will likely be subject to a deductible phase, an initial coverage phase, and finally the catastrophic phase.

In the deductible phase, you’ll pay cash for the amount set by the plan, which will likely be $615 or less. You’ll then enter the coverage phase, whereby you’ll pay the first $2,100 before reaching the catastrophic phase. Once you reach the catastrophic phase, the Part D plan will pay the full costs for the remainder of the plan year.

So my friend told me I should just go with the cheapest Medicare plan. That sounds too simple - what am I missing?

It is too simple! The beginning of a health plan enrollment process should always start with a Personal Health Assessment, which should involve questions personalized to your needs & wants. Understanding your current health and wealth status will drive a plan selection approach. Additional details regarding your current providers (primary care physician, specialists, pharmacies & dentists) often influential in the plan selection process.

I lost my Medicare Card. What do I do?

The best way is to log into your My Medicare.gov account, assuming you have created one. I highly recommend this approach to avoid long wait times if calling Medicare. If you struggle with technology, you can call 1-800-MEDICARE or visit your local Social Security office, and they can assist you!

Who will make medical decisions as to what is necessary to me: my Doctor or the insurance company?

Your doctor makes the clinical decisions associated with your health care. The insurance company may have clinical review processes referred to as prior authorization to ensure established clinical protocols have been followed, and your doctor’s care plan for you is the financially prudent choice

For Medicare Part D, why would someone pick a plan with a high total cost?

If you can receive deductible, copayment, and coinsurance reductions by paying a greater premium, it is possible that a plan with a higher cost makes sense. People who are high utilizers (many medications or few really expensive medications) may be potential candidates. You should have a broker analyze your unique situation and determine if this would be a sensible strategy for you!

Is it better to update your Medicare plan often, or to get a plan that will work long term?

You should review your plan annually with your agent/broker, especially after you receive your Annual Notice of Change (ANOC) document, usually in late September. During your review, it is important to see if your conditions & needs have changed or if your Medicare plan has made significant changes that no longer fit your needs.

Will private hospitals accept Medicare plans?

The decision to participate in Medicare is between the hospital and the health plan. If the private hospital and the health plan can agree upon the contractual terms and conditions, the private hospital will be included in the health plan network. However, quite often, the private hospitals and health plans fail to come to a satisfactory agreement between one or both of the parties involved.

I've been on a Part D plan for a while, and I'm wondering why my generic prescriptions suddenly cost more. Did something change?

There have been several changes in most Medicare Part D plans that may be contributing to the increases you are seeing with your medications. The first may be a deductible, often up to $615, before you get any drug coverage, regardless of the medication. The second is that your copayments and/or coinsurance may have increased. When the annual open enrollment period begins in October, it may be a good idea to conduct a thorough review with your broker/agent before 2027.

Does Medicare part A and B cover urgent care office visits?

Medicare Part B covers urgent care services. You’ll typically have 20% coinsurance after you’ve met your deductible.

Are there plans that allow me to continue to travel anywhere and be covered?

Generally, for clients who travel significantly and have a significant retirement income, I’d point them to original Medicare plus a Medicare Supplement plan that covers international travel. This would give them the flexibility they desire to see the providers they need to see whenever and wherever they may be.

Why do some agents push Medicare Advantage plans over Medigap-should I be skeptical?

If an agent is pushing a particular type of plan, such as a Medicare Advantage plan, without first conducting a personal health & wealth assessment with you, then yes, you should be skeptical!

If a personal assessment is conducted with an individual, there are certainly many cases where Medicare Advantage plans make sense for an individual to consider. People who are healthy but financially challenged with a low fixed income, for example, may benefit from a $0 premium Medicare Advantage plan as they’ll likely never reach the Maximum Out-of-Pocket (MOOP) spending amount and can avoid the monthly premiums associated with standalone Medigap and Part D plans.

These aren’t the only cases where these plans make sense. If someone is pushing you, push back and ask for a complete review before you select a plan.