Preparing for Medicare: Essential Tips from Laura Crouse | Repair The Roof Podcast

Subscribe where ever you listen to Podcasts:

Spotify Podcasts
Apple Podcasts
Google Podcasts

Resources:

In this conversation, Laura Crouse, a Medicare specialist, discusses the intricacies of Medicare, including eligibility, enrollment periods, and the differences between Original Medicare and Medicare Advantage plans. She emphasizes the importance of understanding the costs associated with each plan and the lack of long-term care coverage under Medicare. The discussion also touches on the future of Medicare plans and the potential changes in the healthcare landscape.

Medicare Made Simple: Smarter Choices, Lower Surprises

Your clear-eyed guide to Medicare basics, common traps, and what really drives the right decision for you

You’ve heard the horror stories: someone enrolls late and owes a lifetime penalty. Another chooses a plan for the “free perks,” only to find their specialist is out of network—right before a major procedure. Someone else assumes Medicare covers long-term care… and then discovers it doesn’t, at the exact moment they need it most.

Here’s the good news: you can avoid these costly mistakes. The key is to understand what Medicare actually covers, what it doesn’t, and how your needs—doctors, prescriptions, travel, and budget—shape the right path forward.

This article distills essential insights from a conversation with Medicare specialist Laura Crouse and estate planning attorney Ted Gudorf. Use it to get oriented, ask smarter questions, and prepare for a confident decision during your enrollment window.

The Big Picture: What Medicare Really Is (and Isn’t)

Medicare is a federal health insurance program with multiple parts. Each part covers a different slice of care, and the way you assemble those parts determines your costs, network flexibility, drug coverage, and out-of-pocket limits.

Crucially, Medicare is health insurance, not long-term care insurance. It pays for medical and skilled services (think hospital stays, physician visits, rehab with therapists). It does not pay for custodial care—help with bathing, dressing, toileting, meals, and homemaking—that many people eventually need. Surveys suggest that roughly 60% of Americans mistakenly believe Medicare includes long-term care coverage. It doesn’t.

Why this matters: Your plan selection should account for the gaps—especially prescription drugs and long-term care—so you know your worst-case costs before they happen.

The Four Parts, De-mystified

Part A: Hospital Coverage

Covers inpatient hospital stays, hospice, and some home health care. If you or a qualifying spouse worked enough quarters, Part A typically has no monthly premium. There is an inpatient deductible each “benefit period.” In recent years, that deductible has hovered in the low-$1,600s per period. If you have multiple hospitalizations in separate benefit periods, you may pay the deductible more than once.

Why it matters: That deductible is real money—especially if you’re hospitalized more than once in a year. The right supplemental choice can offset this exposure.

Part B: Medical Coverage

Covers physician visits, outpatient care, tests, durable medical equipment, and more. Part B has a monthly premium (for 2025, discussed as $185), and higher-income households may pay more through IRMAA. Part B generally pays 80% of approved amounts; you pay the remainder unless you add a plan that fills the gap.

Why it matters: You will pay the Part B premium whether you choose Original Medicare or a Medicare Advantage plan.

Part C: Medicare Advantage

Offered by private insurers, Part C bundles your Part A and Part B—and often Part D—into a single plan. Most Advantage plans feature $0 premiums (beyond your Part B premium), networks, prior authorizations, co-pays/coinsurance, and a maximum out-of-pocket (MOOP) limit for the year. Many also include extras such as limited dental, vision, hearing, or a grocery card allowance.

Why it matters: Advantage plans trade lower monthly premiums for more cost sharing and network rules—but you gain a cap on total in-year spending.

Part D: Prescription Drug Coverage

Private drug plans that work with either Original Medicare or are embedded inside many Advantage plans. Plans vary by premium, formulary (which drugs they cover), preferred pharmacies, and tiered co-pays. Miss your initial enrollment when you don’t have “creditable coverage,” and you could owe a lifetime late enrollment penalty.

Why it matters: The wrong drug plan can quietly cost thousands over time—especially if your medications change. Enrollment timing also matters to avoid penalties.

Two Pathways: Original Medicare vs. Medicare Advantage

At a high level, you’ll choose one of two frameworks:

Path 1: Original Medicare (Parts A & B) + Medigap + Part D

  • Flexibility: See any provider nationwide who accepts Medicare—no referrals required.

  • Medigap (Supplement): A private “Medigap” policy helps pay your Part A/B cost-sharing. Popular plans are standardized by letter (e.g., Plan G), so benefits are the same across insurers.

  • Prescription drugs: Buy a standalone Part D plan.

  • Monthly costs

Why people choose it: Maximum provider choice, low unpredictability for medical costs (Medigap can dramatically reduce Part A/B cost-sharing), and no gatekeeping for specialists.

Hidden challenge: Monthly fixed costs can be higher, and Part D pricing trends have been upward. Medigap enrollment has underwriting if you miss your guaranteed-issue window (usually the first six months when you enroll in Part B or at retirement if later).

Path 2: Medicare Advantage (Part C, often with Part D embedded)

  • Structure: One integrated plan from a private insurer; you must have Parts A & B to join.

  • Costs: Many plans have $0 premiums beyond Part B; you pay co-pays/coinsurance as you use care.

  • Protection: Annual MOOP (for example, plans might estimate a typical worst-case scenario near $3,400–$4,500 in-network based on a mix of visits/hospitalization; all plans cap catastrophic at a higher threshold).

  • Networks & referrals: Usually HMO or PPO networks. Out-of-network care can be limited or more expensive (emergencies are covered).

  • Extras: Often include limited dental, vision, hearing, fitness, OTC/grocery cards, and rides—attractive but not the core of coverage.

Why people choose it: Predictable upper bound on in-year costs (the MOOP), lower monthly premiums, and bundled convenience—including a built-in drug plan in most cases.

Hidden challenge: Network limitations, prior authorizations, and plan rules can affect access and timing of care. Choosing solely on “extras” can backfire if your doctors or drugs aren’t a good fit.

Three Curiosity-Driving Insights to Pressure-Test Your Decision

  1. The “Free Plan” That Isn’t Free
     A $0-premium Advantage plan can be the right answer—but only if your doctors and drugs align with the network and formulary. Miss that fit, and you could pay more in co-pays, higher out-of-network charges, or delays due to prior authorizations. The “free” plan isn’t free if it doesn’t match how you actually use care.

  2. The Medigap Misconception
     Medigap can make Original Medicare feel nearly cashless for covered services—but it doesn’t cover Part D drugs, dental/vision, or long-term care. Budget for those separately. And don’t miss your guaranteed-issue window; switching later often requires underwriting.

  3. The Penalty That Never Quits
     Delay Part D without creditable coverage, and you can owe a lifetime penalty added to your Part D premium. Even if you take no medications today, enrolling properly during your initial window can prevent a permanent surcharge.

Enrollment Timing: The Windows that Matter

  • Initial Enrollment Period (IEP): Spans 7 months—the 3 months before your eligibility month, the eligibility month, and the 3 months after. This is your cleanest path to enroll in A and B (and D or an Advantage plan) without penalties.

  • Working Past Eligibility? If you have employer coverage considered creditable, you might delay Part B and D without penalty. Employer size and plan rules matter; coordination is key.

  • Annual Enrollment Period (AEP): Each fall, you can switch Advantage or Part D plans for the next year.

  • Special Enrollment Periods (SEPs): Certain life events (e.g., losing employer coverage, moving counties) let you change plans mid-year.

  • Changing Your Mind: You can go Advantage → Original or Original → Advantage during allowed windows, but Medigap acceptance may require underwriting if you’re outside your guaranteed-issue period.

How to Compare Plans (Without Getting Lost in the Weeds)

Start with your reality, not the brochure

  • Doctors and hospitals: Which providers do you rely on? Are they in-network for a given Advantage plan? Do they accept Medicare assignment if you prefer Original Medicare + Medigap?

  • Prescriptions: List every medication, dose, and preferred pharmacy. Compare formularies, tiers, and prior authorization requirements across plans.

  • Travel and snowbird life: Need nationwide access without referrals? Original Medicare + Medigap often wins for portability. Some PPO Advantage plans are improving here—verify out-of-network terms carefully.

  • Budget rhythm: Prefer higher predictable monthly costs with minimal medical surprises (Medigap)? Or prefer lower monthly premiums and accept pay-as-you-go co-pays with a cap (Advantage)?

Then assess the numbers you can control

  • Premiums: Part B (standard + IRMAA if applicable), plus Medigap + Part D—or a $0 Advantage premium if appropriate.

  • Out-of-pocket exposure: Medigap can shrink this. Advantage caps it with MOOP—compare plans’ in-network and out-of-network limits.

  • Non-medical gaps: Dental, vision, hearing, and long-term care remain separate planning needs.

Finally, scrutinize the fine print

  • Referrals & authorizations: Will you need your PCP’s approval to see specialists?

  • Tiering & step therapy: Will a drug require a lower-cost alternative first?

  • Ancillary benefits: Nice to have—just don’t let a grocery card outweigh oncology access.

Cost Frameworks You Can Live With

If you want national freedom to see specialists:
 Original Medicare + Plan G (or similar) + a well-matched Part D plan often delivers broad access and low surprises for covered medical services. Expect higher monthly fixed costs.

If you want lower premiums and a spending cap:
 A strong PPO Advantage plan with your doctors and drugs in-network can be compelling. You’ll trade referrals/authorizations and network boundaries for a MOOP that limits worst-case spending.

If your prescriptions are the wild card:
 Invest time in the Part D comparison. A few formulary differences can dwarf any premium savings. Re-shop annually—med lists and formularies change.

Long-Term Care: The Most Overlooked Risk

Medicare does not pay for custodial care—help with daily activities that often marks the longest and most expensive phase of care. It will cover skilled rehab after a qualifying hospital stay and hospice near end-of-life, but it will not fund extended in-home aides or assisted living because you need help bathing, dressing, and eating.

Translation: Plan this separately. Whether you self-insure, consider insurance solutions, or use a hybrid strategy with legal planning, you need a deliberate approach well before you need care.

Real-World Tradeoffs (And How to Think About Them)

  • “I love my specialist.” If access to a specific specialist matters above all else, Original Medicare + Medigap usually keeps the path friction-free. If you choose Advantage, confirm that specialist is in-network and understand the authorization process.

  • “I’m cost-sensitive monthly.” Advantage plans (especially $0 premium options) keep monthly costs lower and give you a MOOP. Balance that with potential co-pays and network constraints.

  • “I travel for months at a time.” Original + Medigap offers national consistency. Some PPO Advantage plans offer broader portability with higher out-of-network cost sharing—read carefully.

  • “My meds changed suddenly.” Re-evaluate your Part D or Advantage plan every fall. Formularies and preferred pharmacies shift; your plan should evolve with your prescriptions.

Common Mistakes That Drive Big, Avoidable Bills

  • Enrolling late in Part D without creditable coverage → triggers a lifetime penalty.

  • Choosing solely for “extras.” A generous OTC card doesn’t matter if your cardiologist is out of network.

  • Ignoring MOOP differences across Advantage plans. A lower premium with a much higher MOOP can be a false bargain.

  • Missing the Medigap guaranteed-issue window. Later changes may require underwriting; acceptance isn’t guaranteed.

  • Assuming Medicare covers long-term care. It doesn’t—separate planning required.

What to Do Before Your Enrollment Window Opens

  1. Build your care map: Doctors, preferred hospitals, prescriptions (with dosages), pharmacies, anticipated procedures.

  2. Decide your priority: Nationwide access and minimal medical surprises, or lower monthly premiums with a spending cap?

  3. Run a cost scenario: Tally premiums + likely co-pays + worst-case MOOP (for Advantage) vs. premiums + Medigap + Part D (for Original).

  4. Pressure-test portability: If travel is part of life, verify out-of-network rules in writing.

  5. Plan for the gap Medicare won’t fill: Dental/vision/hearing and long-term care strategy.

  6. Mark the dates: Your 7-month Initial Enrollment Period, plus fall Annual Enrollment every year.

Compliance & Clarity Notes

  • Information here is educational and general. It is not individualized advice or a recommendation for any specific person.

  • Medicare premiums, deductibles, MOOPs, and benefits change annually. Verify current numbers at medicare.gov and with plan documents.

  • Enrollment windows, creditable coverage rules, and underwriting vary by situation. Confirm your eligibility and timing before you switch or enroll.

Your Next Step (CTA)

Get your personalized Medicare Readiness Review.
 Bring your doctors, prescriptions, and travel plans. In one focused session, you’ll see which path—Original + Medigap + Part D or a well-matched Advantage plan—best aligns with your health needs and budget, and how to avoid lifetime penalties and coverage surprises.

Conclusion: Choose Deliberately, Not Default

Medicare isn’t hard because it’s complex. It’s hard because the right answer depends on you: your providers, prescriptions, travel, and tolerance for monthly premiums vs. point-of-care costs. Start with your reality, then choose the structure that supports it—not the one with the catchiest commercial.

Make your choice with eyes open, dates marked, and gaps addressed. That’s how you minimize surprises, control what you can, and turn a maze of options into a plan you can live with.

Transcript: Prefer to Read — Click to Open

Ted (00:00.11)

Hi everyone, this is Ted Gudorf. Welcome to the Repair the Roof podcast. Today we have a special guest, Laura Crouse is with us today to talk about Medicare, one of my favorite topics. Welcome Laura. Welcome, thank you for having me. Hey, you’re a Medicare specialist and I want to dive right into this topic today. What is your role as a Medicare specialist? You know, my role as a Medicare specialist is to go in and you know,

look at every client as an individual. Everyone’s needs are not the same. And so when you approach it, you need to know, what are their concerns? What doctors are important to them? What are their healthcare concerns? What are their long-term goals? What do their finances look like? That all plays a part in fitting them with the best plan and kind of seeing and mapping out the year ahead for them. So what are the basic eligibility requirements

for Medicare. Let’s start with the real bottom line basics. Sure. It is a federal health care plan and typically you have to be 65 years or older. Now there are circumstances to which you can be under 65, but typically you have to be 65 or older. You have to be eligible for Part A, which means you’ve had to work at least 10 hours full time or 40 quarters to be eligible for Medicare Part A. Now you can

by your Part A premium if you haven’t met those qualifications. You have to be a U.S. citizen or you have to have been a legal resident for at least five years. So when you say Part A, what does that mean? It sounds like there are different parts of Medicare. So let’s focus in on Part A. What is that all about? So Part A is your hospital coverage. It is the part that you

that automatically happens when you start to file for social security or that when you turn 65. So it covers things like home care, hospice, things of that nature. And I take it then in addition to part A, there are other parts. Can we talk about that? Yes. So there’s part B. If you are eligible for part A, you are usually entitled to part B. Now there is a premium that comes along with part B.

Ted (02:25.536)

A lot of people who decide to work after retirement or their normal retirement age will put off part B because that is like your doctor’s visits, your specialist, your medications. And usually if you have credible drug coverage through your employer, you don’t need part B right away. So part A is hospital and part B is your medical.

So if you work after age 65, you’re still eligible to go on Medicare. But as I understand it, maybe you’re not required to depending upon the size of your employer. Right. I tell all my clients, you’ve worked for that part A. you should. So if you retire on time and you file for Social Security.

Like I said, it automatically starts your part A. But if you decide to work, you still have worked for that part A. But it does depend on the size of your employer. If you work for an employer who has less than 20 employees, you’re probably better off going ahead and signing up for that part A for sure. If you have more than 20 employers, your employer insurance will be your primary insurance. Your part A will be your secondary insurance. But again, you worked for it.

I always suggest or recommend that you go ahead and pick that up. So in addition to the A and B, I think that’s pretty clear. One’s hospital, one’s physician. Right. of look at it that way. What other parts are there to Medicare? What else does it cover under what parts? Are you talking about like, is there part drug plans and part C? So now we’re looking at Advantage plans. So

Part A is your hospital, part B is your medical. What happens, or what kind of has happened over time, if you want to go back and look at some history, is that people used to retire with benefits for the rest of their life, and that just doesn’t happen anymore, unless of course you’re military. Those people get TRICARE for life, and there’s certain government positions that you’ll retire with some health benefits. But when you retire now,

Ted (04:46.254)

you are relying on the federal health plan. And that just doesn’t cover your expenses. It absorbs the cost of some of your expenses, but not all of your expenses. And to just kind of give you a glimpse, I think that a hospital deductible, if you were going to the hospital and have a hospital stay, the deductible is over 1,600 for 2025. So if you can imagine, if you have multiple hospital stays in a year, that can be.

pretty costly and that’s not even including the doctors you’re seeing, your medications or anything like that. And your Medicare doesn’t cover prescriptions. So that’s a separate cost. So what happened is the federal government looked at these, looked to the private carriers and they said, listen, we need help managing our Medicare system. And that’s kind of how part C happened. It’s really not a federal healthcare plan. It’s a private plan.

You have to have Medicare Part A, which is your hospital, your Medicare Part B, which is your medical, to qualify for Medicare Part C. Those are your advantage plans. Now, in addition to then A, B and C, is there a Part D? There is a Part D. That’s your prescription drug plan. You have to have show that you’ve had credible drug coverage.

There’s also an enrollment period to where you have an opportunity to pick up that part A and that part D. If you don’t pick it up in a timely manner, you could pay a late penalty. I’ve run across a lot of clients who, you know, they retired, they weren’t on any medications. You know, they were healthy. They didn’t feel the need to pick up a part D. They were not informed. And so they went years without picking up a part D or credible drug coverage.

and they pay a penalty for that the rest of their life if they don’t pick up that Part D. So when should somebody think about applying for Medicare? You know, I’m 54 and I’m already starting to think about, know, you get to a certain age or your your kids are getting older and then you start to think about that next phase of life. And I think it’s good to start thinking about what that’s going to look like for you, because it’s costly, you know, no matter.

Ted (07:03.948)

what way you look at it, health insurance is costly and it’s hard even with just a prescription drug cost and a lot of these part C plans are premium free plans, which means you’re not paying anything for the plan. That doesn’t mean there’s not out of pocket cost, but the plans are free, the prescription drug plans are free, but you still have to pay for the prescription, you still have to pay for the plan. So I think it’s…

The earlier the better. You need to think about what your future is going to look like once you retire. Well, when’s the sooner I can apply? What’s the soonest you can apply for Medicare? You have the three months. You have a seven month window. You have the three months prior to your 65th birthday, the month of your birthday and the three months after your birthday to apply for Medicare Part A.

So you have a seven month window to apply and let’s say I don’t apply and let’s assume I don’t have any coverage at all. No credible coverage. If I later want to join, am I allowed to join late? And if so, is there a penalty? So you have an initial election period. If you miss that period, now you have to wait until there’s an annual enrollment, which starts in October and ends in December.

And yes, for every 12 month period that you go without enrolling in the plans that you should have, there’s a late penalty. Very good. So let’s talk about.

Original Medicare. Traditional, original Medicare. Okay. And then let’s compare that to Medicare Advantage. And let’s talk about what is the difference between the two. Okay. So original Medicare is the Medicare that we’re all, if you’ve worked, if you have a work history. And you know, and I should also say too, you know, when we were talking about the eligibility requirements, if you’re married,

Ted (09:12.8)

and your spouse has that work history, that also makes you eligible for those Medicare benefits, even if you’re divorced, as long as you were married for 10 years. So once you turn 65, that part A and that part B is your original Medicare, and it pays for some expenses. I have a quick list here. So your original Medicare,

you can use any doctor, you can go to any hospital system that takes Medicare. If you choose an advantage plan, you’re usually tied to a network for cost savings reasons. And it depends on where you live. So what state you live in, what county you live in, that will probably dictate a lot of what network you’re in. If you have original Medicare, you don’t have to have a primary care.

you don’t have to have a referral for any specialty visits. If you have an advantage plan, a lot of times that is the case. You have to choose a primary care. That primary care usually is the one that has to make the referrals to any specialist that you see. Also with original Medicare and with Advantage, you have that Part B premium. That really doesn’t go away. There are some

Advantage plans that kind of cater to veterans and they’ll kind of buy back their Part B. The only other way that you’re going to get your Part B premium pay for is if you are Medicaid. So your your resources are limited, your income, you know, usually you’re living in poverty if they’re going to pay your Part B premium. So on the if I understood you correctly and correct me if I’m wrong. So if I have original Medicare.

And that means I have part A and B. And if I want to cover some of the other costs, then I can come to somebody like you and do a Medicare supplement type plan. Did I understand that correctly? Right, you can. Because your original Medicare, and I kind of touched on this briefly earlier, your original Medicare does not come with a prescription drug plan. It is solely medical and hospital. So

Ted (11:37.902)

that can become pretty costly. So unless you have just a ton of money just to spend on your medical, you are kind of left within a situation where you’ve got to decide, do you want to go towards an advantage plan, which is your part C, or do you want to go towards a supplement plan? Because your original Medicare doesn’t cover things like drugs, it doesn’t cover dental, it doesn’t cover vision. So those things-

But let me ask you this does does your original Medicare cover 100 % of your physician bill 100 % of your hospital bill? No, it does not. And so when I was talking earlier, so what do you generally what generally do you tell people in terms of what it will cover? It covers, you know, every year it’s different. So for like I said, for an example, like if you were in the hospital today, it covers about 80%.

If you were in the hospital after your deductible, so if you went into the hospital today for a 60 day stay, you’re gonna pay $1,600 off the top and that’s just your deductible after you pay your deductible, then it’s covered. But that doesn’t cover your doctor’s, your medications. That’s an additional cost, you know, on top of your medical deductible for your hospital stay. So the advantage plans,

they have a max out of pocket. So when you choose a plan, and the way I have clients choose a plan is I have them look at their doctors. What doctors are important to you? What medications are you on? What medications do you have to have to stay healthy? Then we look at things like their finances, because some people, they just really can’t afford a premium.

Some people know they’re gonna end up in the hospital one or two times a year. So we have to look at things like that to see what their overall costs are gonna be for a year. So part C kind of gives you kind of more security into what’s the worst case scenario that’s gonna happen to me this year medically. Because with original Medicare, there is no limit. It doesn’t stop. If you went into the hospital several times and

Ted (13:59.882)

It was more than a 60 day window. You’re paying that deductible every single time you go into the hospital. At least with a Medicare Advantage plan, you know what your max out of pocket could be. You know what your worst case scenario is going to be. Does the Medicare SUP pick up that deductible at all or is it after the deductible? So now your Medicare supplement is a totally different plan. So that’s considered like a Medigap plan.

That fills in what traditional Medicare does not cover. I like Medicare supplement plans. You definitely have to plan for that retirement because those come with a pretty heavy premium. You have a six month enrollment period where there’s no underwriting for pre-existing conditions when you turn 65 or when you retire, you know, so that it costs the same no matter what.

That totally fills in the gap. So everything that Medicare, your original Medicare doesn’t cover, your Medicare supplement will cover, but it’s at a pretty heavy premium and it also doesn’t cover your drug costs. So in addition to the premium, you have to pay for a prescription drug plan. It also. So let’s break this down in terms of cost. OK, let’s compare it.

So original Medicare, what are the normal charges that we have to pay to get part A and part B? So you don’t pay anything for the part A unless you don’t have the work history. OK. You do have to pay the part B and it doesn’t matter what plan you’re in. You’re going to have to pay that part B premium. What does this year? This year in 2025, it’s hundred and eighty five.

And that usually goes up every year. And I assume that as I have found out that if you’re still working, you may have to pay more than the one eighty five. Right. That is totally based on your income. So most people pay one hundred and eighty five. You can get online at Medicare dot gov. It’ll show you because it changes from year to year.

Ted (16:25.558)

I think the max is if you’re making more than a half a million a year, you’re claiming on taxes. It can run you over $600 for that Part B premium. we, Part A, no cost. Part B, we pay this, let’s say $185 premium. Then we want to add a Medicare SUP. What is the range of

that we’re going to pay for a Medicare SUP plan? So, know, Medicare SUP is interesting because there are usually about 10 plans and they’re all designated with letters. Those plans, so one of the popular plans is a Plan G. It is a Plan G whether you’re in Ohio, Indiana, you know, and it covers the same things. The policies are pretty much the same. It just depends what carrier you go with, what private carrier you go to.

I have seen MedSupp plans under 100 and I’ve seen them over 300. So it’s customer service, they’re about the same. I really don’t know why someone would pay 300 instead of 100 and they change from year to year. But a Plan G is a Plan G no matter where you’re at, no matter what state you’re in and it covers the exact same things.

And while we’re talking 100 to 300, we’re talking per month, right? We’re talking per month. Right. And then you have the prescription drug plan, too, which those prices are going up as well. So what are you saying in terms of pricing a Part D plan? So they were expected to triple last year, but they didn’t because the federal government kind of stepped in and said, hey, let me let us help you with these prescription drug plans so that it wasn’t such a shock.

They the numbers are just now coming out. haven’t seen them all. They just actually some of them are have been released just earlier this week. They’re expected to triple. Last year, I saw prescription drug plans range from like thirty five dollars to seventy some dollars. They’re expected to go up to about one hundred hundred twenty dollars for a prescription drug plan. So that was thirty five to seventy per month, right? Per month on top of the supplement plan.

Ted (18:49.774)

Yes. All right. So if we’re going to stick with original Medicare, we’re going to get part A coverage, part B coverage, and then we’re going to do a Medicare sub to cover the things that A and B don’t pay. Right. And we’re going to end up with a separate prescription policy under part D. Right. We pay one hundred and eighty five dollars for the part B. We might pay up to one hundred dollars for the sub, perhaps maybe more.

And then Part D somewhere between 35 and $75 currently per month. So you add all of that up and that gets to be a pretty significant amount to stay with original Medicare. So I guess the alternative that is out here in the private sector in the private insurance market is what you were referring to as Medicare Advantage plans. Yes. And those Medicare Advantage plans necessarily include

A and B coverage? Yeah, it has to you have to have A and you have to have B to participate in an advantage plan. So what are we seeing in terms of costs for the Medicare Advantage plans? And is it wide invariant? And how many companies are there out here in the marketplace that are offering the advantage plans? So there are a lot of companies. I currently carry 10 private carriers.

There are well more than that in the state of Ohio. I carry the major ones and then the ones in Dayton. They vary in price. You can usually find a no premium plan, but it depends on the type of plan that you get that can maybe sometimes dictate the cost of that plan. But these plans, you’ve all seen the TV commercials that promise you dental and vision and grocery money and transportation.

At the base of all of these advantage plans, at the bare minimum, they have to offer you at least what Original Medicare offers you. So when that conversation happened, you know, the federal government said, you know, you can manage these, but you have to at least offer them the, at least what Original Medicare offers. After that, you can give them whatever you want, but at the bare minimum, what Original Medicare gives you. So you have to have your A, you have to have your B.

Ted (21:18.086)

Most of the Advantage plans offer a prescription drug plan. There are some that don’t because there may be somebody who has a prescription drug plan through maybe their spouse. So maybe they don’t need a prescription drug plan. But most of them have a prescription drug plan embedded in the Advantage plan. So help me understand the pricing structure on the Advantage plan when you were saying there’s no premium. Help me understand how that could be.

Okay, most plans have no premium. There are plans with premiums. Most of my clients can find a plan without a premium, but that doesn’t mean that you don’t have out of pocket cost. Your drugs still cost money. You have what’s called a moop, a max out of pocket cost. And so you may be comparing two plans and in one plan, you might have a max out of pocket of, you

I’m just gonna throw out an arbitrary number, like 3,400, because that was one of the lowest out of pocket plans. And this is an estimate. They based it on a visit to the emergency room, a week in a hospital, basic medications, a visit to a doctor, a visit to a specialist. That’s how they come up with these numbers. All of them have a catastrophic of 8,500.

So at least you go into the year knowing that you’ll never pay more than that. And for just maybe one hospital stay, worst case scenario, maybe your max, they anticipate your max out of pocket being like 3,400. But you might have another plan without a premium that the out of pocket costs are 4,500. And you gotta look at those plans and see why is that so? It could be the type of plan that you’re in because there’s different types of plan. It could be that this plan is giving you

all these bells and whistles and they’re enticing you with this food card, but this plan is just giving you the basics. Like they’re not enticing you with this big money card or all this money in dental. They’re just saying, hey, listen, we’re gonna give you the lowest max out of pocket, but we’re not gonna give you all these bells and whistles that they’re promising on TV. So you’ve gotta kind of really look, I think it’s as easy, especially with the senior population and especially people who are

Ted (23:43.436)

you know, they’re strapped for money and they’re living paycheck to paycheck. You know, when you hear the promise of $100 food card, sometimes you don’t look at the whole entire picture and you may pick a plan that, you know, potentially could cost you more out of pocket at the end of the year. So you really have to look at the entire plan.

It sounds complicated to be able to analyze whether I should go on original Medicare or Medicare Advantage and then within the multiple Medicare Advantage plans, if I decide to go that route, it seems challenging. So what I take it is that you’re there to help guide people through all of these decisions based upon their current situation.

Correct. It’s definitely not everyone fits in one box kind of situation. is, you know, and it can even vary from husband to wife, depending on which plan you’re putting someone in. You know, a supplement plan is good if you’re getting ready to retire and you’re someone that has saved and you can afford those premiums. know, a Medicare supplement’s great because you can take that plan anywhere in the United States. You can go to any doctor that provides Medicare services.

if you’re more strapped and you’re not someone that’s going to travel and you really can’t afford a premium and maybe you’ve got some house concerns, then we’re going to look at maybe something different because underneath the umbrella of advantage plans, there are different types of plans that may work with you. And the other thing too is a lot of these advantage plans are becoming a little better as far as portability, being able to take them other places beside your network. Well, that is probably

most people’s biggest concern is what happens when they got to go out of network. What does that look like? What do they have to do to be able to go out of network? And what happens when that occurs? So any emergent care or any urgent care is covered. Now, it will probably be at a higher cost sharing because you’re not in your network, but it is covered.

Ted (26:01.206)

And then depending on the plan, and again, every plan is very specific and it will spell out to you like what happens if you are to receive services or dialysis services or any kind of medical services outside of your network. You can go outside of your network, but it is typically gonna be at a higher out of pocket network cost to you.

Ted (26:29.102)

So I guess you got to have somewhat of a crystal ball. Having said that, if I start off with original Medicare, I want to switch to an Advantage plan or vice versa, start off with an Advantage plan, but think maybe I should have been on original Medicare. Are you allowed to switch back and forth or are there some limits on being able to do that? You can switch back and forth.

But often there are enrollment periods in which you can do that. So it just depends on the circumstance, but there are special election periods that allow you. If you are an original Medicare and annual enrollment is over, no, you can’t switch at that point. You’ll have to wait until the next enrollment period.

It depends, you know, a lot of it depends if you’re going from supplement to advantage or advantage back to supplement. But there are, you know, that’s when you need to talk to an agent because there are special election periods. There are times where you can, you know, go back if something wasn’t working for you the way you saw it, you can go back to your original Medicare. Do any of the policies, whether it be original Medicare or Medicare and Gannies plan, do any of them require any kind of medical underwriting?

or are they guaranteed issue? So the Medicare Advantage plans don’t require any underwriting at all. You you just have to make sure that you’re again, you’re eligible for A and that you’ve picked up your part B. Now your Medicare SUP, if you do it within the first six months of retiring or of 65,

there’s usually no, there is not any underwriting for any pre-existing conditions. Now I’ve heard different things, I’ve not run into it myself. I have been told, for people who are still working, not to pick up their part B right away, because that sometimes can start that clock of that six months. And you don’t wanna mess up any issues with underwriting if they decide they wanna go with a supplement plan.

Ted (28:41.034)

after they retire, if they’ve decided to work after retirement age. So does that mean that if somebody has gone on original Medicare, does a Medicare sup and wants to change out of that Medicare sup, they might be subject to underwriting with any new company? Does it mean that? Yes, it could. Or like if you went from a Medicare sup and then you decide to go to a Medicare advantage and then all of a sudden you want to go back to a Medicare sup, then

than your subject to underwriting. I got you. Very good. Let’s talk a little bit about something near and dear to my heart, and that is somewhat related, but a little bit different. Let’s talk about Medicare long term care coverage before we wrap this up. What does Medicare typically provide coverage for as it pertains to long term care? They don’t pay for anything.

Medicare is a federal health plan. And you know, I’m also in the healthcare field and I see this all the time. I just read an article recently and they cited that 60 % of people who retire believe that there is some sort of built-in long-term care for them in their Medicare and that’s just not the case. Medicare is healthcare. It is…

It is the system that provides you skilled services, your nursing services, your doctor services, your medications, know, well, not your medications, but you your medical. Long-term care is custodial care. is helping you with your activities of daily living, like your bathing, your dressing, your toileting, homemaking, adult daycare. Those are two separate things.

So I suspect, I guess Medicare will pay for hospice care at the end of life if we’re terminal, but you gotta be terminal to get that. So that’s really not custodial care. The only other thing I can think of where Medicare may enter into it is for my clients who go in the hospital and maybe need some rehab for a short period of time. I guess Medicare will pick up the rehab. So they’ll pay for rehab because it’s skilled. They consider that skilled care.

Ted (31:03.278)

And they’re not going in there just to receive custodial care. They have to require the skill of either a nurse or a physical therapist or an occupational therapist. I work in home care and we do provide aids that will come in. Our aids are aids that come in and are with you three or four or five hours a day or every day. Medicare says, hey, you were in the hospital, you were ill.

understand that you need some skilled care. So you know, you have a nurse out there, physical therapist, and maybe they’ll pay for an aid, but that aid can’t stand alone in that house. That aid can only be present with skilled services of a nurse therapist. So once the skilled service stops, once the patient doesn’t need the nurse anymore, once the patient doesn’t need any rehabilitative services, that aid has to leave as well. They can’t coexist, they have to coexist together. They can’t be alone in that home.

It’s short-term care. Yeah, that’s important for everybody to understand. When you look at what’s happening in the country today and you’re looking into the future, are companies kind of going in and out of the Medicare Advantage world? Do you see that happening in any significant way? What do you mean? Companies that, insurance companies like, CareSource or somebody like that that’s providing Medicare Advantage, do you see any of those companies

maybe entering the marketplace or leaving the marketplace. Is there any concerns about that? I haven’t seen any, you know, I there’s it’s, you know, it’s lucrative for these private insurance companies for clients to choose them to manage their health care needs because the federal government sets the money aside for those private carriers to take over the management of their care. I, you know, it seems like that’s it’s not going anywhere. This is

the way it’s gonna be. don’t see Advantage plans going anywhere. I think they’re here to stay. I think that people are not, and most people are not in a financial situation to pay the heavy costs of supplement plans and the rising prescription drug plans. And this is the only way that they can manage their care. If you were gonna project the future, say, over the next two or three years, do you see any major changes?

Ted (33:24.686)

I do in the supplement world, I mean, I guess that’s to be seen, but those prices are expected to continue to go up. But at the same time, you know, we’ve been hearing as well that a lot of these advantage plans are gonna, you know, they see what the client needs, they hear what the client needs, know, clients wanna be able, they don’t wanna have to stay in their network, they wanna be able to travel to Florida, they want more portability in their coverage. so,

I think we’re seeing a little bit more of that too. We’re seeing them kind of create plans and become more creative, not that they’re supplement plans, but that they kind of more mimic a supplement plan and give you a little bit more freedom and flexibility in your plan without it being a supplemental plan. Well, very good. I see we’re out of time here, Laurie. If individuals would like to contact you to talk about…

their choices for Medicare, how would they go about that? You can call me at 937-470-7137. And I also have an email, it’s LSCROUSC, that’s Crouse, 1227 at iCloud.com. Great. Well, Laura, thanks for being with us today. I really learned a lot.

I always appreciate those who can educate me so I can help my clients. Because at the end of the day, I know that’s the business you’re in and that’s the business I’m in. It’s trying to help our senior citizens make better decisions. Thanks so much for being with us. Thank you.

Back to All Episodes