Medicare & Insurance

Have you EVER read, listened to or viewed the Medicare .gov Publication of “MEDICARE and YOU”?  Cover to CoverIt covers all the Parts of Medicare and how they work for you based on your choices.   It covers how a Medigap plan works with your choice of Traditional Medicare.   It also covers how benefits a covered by Traditional Medicare specifically. If you pick a Medicare Advantage plan (every year) [Medicare Part C] as your choice in how you get your Medicare benefits, do you sit down and read your Explanation of Coverage from your selected insurer?This covers how you get your Medicare Benefits under the Medicare Advantage option and what you pay for specific covered services - specifically and for this chosen insurer. If you do one or both of these things - does it help with your understanding of the Medicare program? Same thing would be true of Part D -Standalone plans if you are using Traditional Medicare - PDP (Prescription Drug Plans)Included Part D

FROM THE ARTICLE. AARP is fighting for a permanent extension of savings that lower the price of Affordable Care Act coverage. By Miriam Cross, AARP. Published September 19, 2025. Charlene Sterlace is feeling the pinch of higher health insurance premiums already.The 60-year-old New York state resident has purchased insurance since 2019 through the state’s health insurance Marketplace enacted under the Affordable Care Act. She remembers her rates plunging during the pandemic when Congress enacted new tax credits. “I was so grateful,” she says. USE LINK BELOW TO READ THE ARTICLE. https://www.aarp.org/advocacy/aca-tax-credits-expire/

I’d say this is a good move and one that should benefit those with a Medicare Advantage plan - but remember they do have 30 days to make any changes from the date they are aware of them.  Providers can go in and out of network at different times since their contracts with the insurer are signed at different times.   When seeing a new provider it is always a good idea just to double check with their office that they are providers in your insurance network group - that’s for any kind of insurance - even Traditional Medicare.   ModernHealthcare.com 09/18/2025 - CMS orders Medicare Advantage plans to disclose provider networks My access to this ModernHealthcare source is limited so I am posting it only as a summary but also I am posting the CMS final rule that is in the Federal Registry - From the Modern Healthcare link -Medicare Advantage insurers will be required to submit provider directories to the Centers for Medicare and Medicaid Services next

Fierce Healthcare.com 09/17/2025 - Johns Hopkins, UnitedHealthcare officially end talks after failing to come to terms on new contract  Negotiations went nowhere so they are ending it -from the link [copy paste] Hopkins providers have been out of UnitedHealthcare’s network for an estimated 60,000 patients, mostly in Maryland, but also in Washington, D.C., and Virginia, since Aug. 25, the Baltimore Banner reported. Those 60,000 patients will have to find new providers or pay higher out-of-pocket costs to continue to see their doctors and get care at Johns Hopkins hospitals. Johns Hopkins Medicine spans more than 50 total care locations, including six hospitals, and serves patients in Maryland, Virginia, Washington, D.C. and Florida. Both parties are warning patients that Johns Hopkins’ hospitals and other facilities are now out of network for enrollees in UHC’s employer-sponsored commercial plans, Individual Family Plan, Medicaid and Medicare Advantage

FROM THE ARTICLE. By Leigh Purvis, AARP Public Policy Institute. Published September 17, 2025. Medicare Part D plans have been subject to numerous changes and challenges since the program was implemented in 2006. In some ways, plans appear to have responded similarly; however, they have also diverged in important ways. The long-term trends highlighted in this report also suggest that recent Part D plan market changes reflect a confluence of factors. Future efforts to reform Medicare Part D should reflect the reality that Part D plans are increasingly distinct and ensure that Medicare beneficiaries retain the ability to choose the coverage option that works best for them. Read the full report. USE THE LINK BELOW TO READ THE ARTICLE. https://www.aarp.org/pri/topics/health/coverage-access/stand-alone-medicare-advantage-prescription-drug-plans/

FROM THE ARTICLE. The Big Choice: Original Medicare vs. Medicare Advantage.Which path you take will determine how you get your medical care — and how much it costs. By Dena Bunis and Kimberly Lankford, AARP. Reviewed by Xavier Vaughn, MPH.Published July 01, 2020.➡️[*** Updated September 08, 2025. Key takeaways![*] Original Medicare has many parts. Medicare Advantage is all-in-one.[*] Original Medicare lets you use any doctor. MA is more limited. ​[*] Both must provide same care. MA costs differ from original Medicare.[*] Original Medicare goes anywhere in U.S. MA has geographic limits.[*] Many states’ Medigap rules make leaving Medicare Advantage hard. USE LINK BELOW TO READ THE ARTICLE. https://www.aarp.org/medicare/original-medicare-vs-advantage/

 This is just a reminder for anybody that currently has a Medicare Advantage Value-Based Insurance Design (VBID) Model this year.  They are ending this program in 2025.   Some of the design features may not be lost since enrollees who choose to remain in MA will likely be able to access many of the same benefits after VBID’s termination (e.g., transportation to medical appointments, healthy food assistance), because many elements of the VBID model have become benefits that can be offered in the MA program. The SSBCI  ( Special Supplemental Benefits for the Chronically Ill ) is continuing and also allows MA plans to offer similar interventions to those available under the VBID model. MA plans will be able to leverage similar pathways and help enrollees maintain access to supplemental benefits that meet their needs.  For a SSBCI plan, from what I understand, there will be a specification that the specific chronic illness - one or more -  

Watch your mail to make sure that you are still gonna be covered by any state Medicare Savings Program - part or full Medicaid coverage - that you currently have or for any advice notifying you that have to re-apply. Medicare.gov - Medicare Savings Programs  These are for the 2025 income / resource limits.  The income and resource limits (in states where there is a resource limit) change every year but will not be known for 2026 until the Spring.     

Are YOU going to keep what you have had or shop around?  🤔 Take care,Nicole (Medicare Forum)

BaltimoreSun.com- 09/02/2025 - Maryland market threatens to push more Medicare Advantage plans out of the state  So what would you do IF all or a big majority of Medicare Advantage plans disappeared in your state and you had to go on Traditional Medicare but access to a Medigap plan was out of reach financially? I am pretty sure that there will be a solution to this dilemma in Maryland - they have been dealing with it for a very long time but then again, maybe not.  Worth at least thinking about it if it might affect you and your benefits. I mean, beneficiaries would still have Traditional Medicare to go to and there would be a special guaranteed issue (SEP) period for a Medigap plan if one’s Medicare Advantage plan closes up shop in a state.  Course, some of the Medigap plans may be out of reach based on their monthly premiums but others may not be - like the High Deductible Plan G -  I urge ALL beneficiaries to review their [whatever] Medicare

Becker Hospital Review 06/30/2025 - CMS to add prior authorization for traditional Medicare services   This really isn't a big deal but I thought I would keep the beneficiaries here abreast of these new items that are being added for prior approval under Traditional Medicare.  Each is more specific in how it is described here in a simple fashion.  Your doc or specialist should know if any procedure you are having would need this extra step of OK because at present it is more of a test to see the results. from the link ~CMS has unveiled the Wasteful and Inappropriate Service Reduction model, a new Innovation Center initiative that will add prior authorization for some traditional fee-for-service Medicare services. Under the model, CMS will partner with companies specializing in AI and machine learning to test ways to provide an improved and expedited prior authorization process for certain Medicare services. Companies hired to manage the

From the NYT... UnitedHealth has threatened journalists, activists and a doctor with lawsuits, often invoking last year’s murder of Brian Thompson, the chief executive of the company’s health insurance division, to deter negative coverage. We should NOT be condoning Threats!   I am starting to look for another Supplemental Plan... As we have many choices for the exact same coverage and I personally will not pay for companies to act in a threatening manner.   -Bill 

Started getting phone calls yesterday - obvious robo-voice saying "Medicare has just released a new Inflation Relief Package for Texas".   Starts asking for age, etc. I suspect it is a new scam, phishing for information.  Has anyone else gotten these calls ?

FROM THE ARTICLE. AARP Endorses Senate Legislation to Stop Medicare Advantage Plans’ Excess Billing.Bill would curb plans’ ability to inflate patient diagnoses, increase government payments. By Tony Pugh, AARP. *** There are 3 comments on the AARP website. Stop by to add yours. **? Published July 16, 2025. AARP is backing bipartisan congressional legislation designed to stop Medicare managed-care plans from inflating patient diagnoses to boost their payments from the federal government.This practice from privately run Medicare Advantage plans, called “upcoding,” is expected to increase the cost of care for Medicare Advantage plan enrollees by $40 billion this year, compared with the cost to cover similar patients in original Medicare, according to the Medicare Payment Advisory Commission. USE LINK BELOW TO READ THE ARTICLE. https://www.aarp.org/advocacy/medicare-advantage-excess-billing/

I went to change from UHC supplement G+ to G as that would save me about $70/mo. Getting actual useful information out of the medical underwriting people is like pulling teeth and then some.  I failed - not because I should have but because of mistakes in my medical record (eg coding errors and in two cases people listing in my visit notes issues I neither saw them for nor have). As a result of that in care everywhere (where EPIC/MyChart parks your diagnoses) I have wrong things (that are causing me to fail - although it took 3 phone calls to finally get a list). And some wrong codes have been listed with billing me. I have corrected all but 2 things on that list and can't figure out how to do those last two. In one case I called the head of billing and she had codes corrected in their system and then re-submitted the bills with the corrected codes.In the other two cases I had one person fix his visit notes but can't get him to report this to billing so they can fix the

I have gone to several different optometrists during the past several years for what I believe are routine eye exams and got new eyeglasses when my prescription changed. I believe those exams were pretty much the same at each place, and included “refraction” to determine my eye glasses prescription, plus they checked my eyes for glaucoma and cataracts, and looked at my optic nerve - none of which I’ve never had any issues, luckily.   These exams each took about 30 minutes each optometrist. Two of these optometrists charged me about $125.00 for the exam, which I paid.  The 3rd optometrist charged $253.00 for the exam, asked me to pay them $45.00 for the refraction portion of that charge (which Medicare does not cover), which I did pay them, and then they billed Medicare for the remaining $208.00 (which Medicare subsequently paid to them). I have looked at the Medicare website, all of the invoicing codes and descriptions for this optometrist’s billing to Medicare

What is AARP's position on Medicare's soon to be enacted pilot program in six states that would require prior approval for certain medical procedures? 

 I have recently been diagnosed with cancer.  Fortunately, I have a Colonial cancer policy to assist my regular health insurance and medicare coverage.  Is there someone with AARP that can assist me in filing my claims?  I am insurance challenged. 

Medicare Program; Implementation ofPrior Authorization for Select Servicesfor the Wasteful and InappropriateServices Reduction (WISeR) Model Has anyone heard about this going into effect? Shouldn't we be concerned? It is going to impact 6 states to start with. This is for standard Medicare. New Jersey, Ohio, Oklahoma and Texas, Arizona and Washington. It will mostly impact procedures that deal with pain mitigation.  

I could not find the HOUSING board so I am posting this here just so you can stay informed at what some states are doing for the elderly/disabled. KFF Health News 08/18/2025 - Health Care Groups Aim To Counter Growing ‘National Scandal’ of Elder Homelessness  Medicare.gov - PACE from the link ~Program of All-Inclusive Care for the Elderly (PACE) is a Medicare and Medicaid program that helps people meet their health care needs in the community instead of going to a nursing home or other care facility.If you join PACE, a team of health care professionals will work with you to help coordinate your care. Read a lot more at this Medicare link to tell you all about the PACE program - Does your state have a PACE program?Medicare.gov - What States Have A PACE program  CMS.gov- Program of All-Inclusive Care for the Elderly (P.A.C.E.)    

  It is possible to do, without underwriting, but it takes staying on top of it and making sure that the timing is perfect. And this may also involve managing your health care expenses for the time that one is under the MA plan. Medicare.gov - Learn How Medigap Works  from the link ~  Trial Rights:If you drop a Medigap policy to join a Medicare Advantage Plan for the first time, you’ll have a single 12-month period (your trial right period) to get your Medigap policy back if the same insurance company still sells it once you return to Original Medicare. If it isn't available, you can buy a Medigap policy you qualify for that's sold by an insurance company in your state (except for Plans M and N). You may also have an opportunity to enroll in a Medicare drug plan at this time.

Does Anybody Have Their Medigap Policy with ALLSTATE? If so, have you gotten a letter from them on closing out the plans (closed book) ?You can keep the plan but they will be selling no more to new beneficiaries.  This is gonna cause your premiums to rise down the line.    Pay attention to any communication that comes from them on your Allstate Medigap plan.  

Worth the read:KFF.org Health News - 08/15/2025 - Breaking Down Why Medicare Part D Premiums Are Likely To Go Up  excerpts from the linked article ~Medicare enrollees who buy the optional Part D drug benefit may see substantial premium price hikes — potentially up to $50 a month — when they shop for next year’s coverage. Increases are expected to mainly affect stand-alone Part D plans, not the drug coverage offered as part of Medicare Advantage, the private sector alternative to original Medicare. Policy experts say premiums are likely to go up for several reasons, including increased use of some higher-cost prescription drugs; a law that capped out-of-pocket spending for enrollees; and changes in a program aimed at stabilizing price increases that the Trump administration has continued but made less generous. One thing is surer than ever, say many policy experts: Beneficiaries should not simply roll over their existing stand-alone Medicare drug plans. ===

Open Enrollment for Part C (Medicare Advantage Plans) and Free Standing Part D Prescription Drug Coverage plans will be coming out later in the fall for everybody to review their plans.  Open Enrollment starts October 15 - December 15 for 2026 plans. There is gonna be some changes again this year - like some PPO plans will go away and there will also be some changes to the rules governing the Prescription Drug Plans. You should get something from your private insurance company by about October 1 and you need to read and take heed of what changes are being made to your plan and then make any necessary changes.   If you need help with deciding this, your state offers some help  and of course, there are LOCAL Medicare Plan brokers that can also help you in deciding which plan maybe the best for your and your needs.   The Medicare insurance marketplace is going thru some changes and it is important for you to make sure that the plan you need is the p

I Have been paying on my insurance acquired through AARP for the last 14 years. Handled ultimately by N.Y. Life. I retired July 2021 and in July 2022 I was notified that my rate would increase by $41.00 per month for the next 5 years. It would increase again in another 5 years. Let's remember that retired means fixed income. The notification letter states that you can change to a permanent plan which will prevent further rate increases. I expected that to mean my rate would be the same. Nope. I called NY Life and was hit with the bait and switch information. In order to have a fixed rate I would have to pay over $300 / month! That would be a 300% increase in monthly payments! Being irate and appalled I requested to cash the policy out and go somewhere else. Low and behold the policy I have been paying into, recommended by AARP,  is one that does not gain portfolio value. Read: NO CASH OUT VALUE! In order to benefit from this insurance I have to die and in the mean time keep paying