13 Things Medicare Won’t Tell You

Updated: Feb. 21, 2023

Medicare provides health coverage for than 57 million people—it's a godsend, but it can be a challenge to navigate. Here's some insider know-how that will help you put the Medicare pieces together.

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Tap into savings programs

There are Medicare Savings Programs that can help pay for Part A and B premiums and out-of-pocket medical costs associated with deductibles and co-pays. “In addition, growing numbers of seniors who qualify for Medicaid are unaware of their eligibility for special Medicare Advantage plans that offer broader provider networks and richer medical benefits than available under Medicaid alone,” says Lisa Zamosky, senior director of consumer affairs for eHealthMedicare.com. If some of these Medicare terms sound like alphabet soup, this Medicare glossary of terms and definitions can help.

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Use expert resources

Customer support teams for your Medicare or Medicare Advantage providers can be extremely valuable assets. They have the personalized data and resources to help make recommendations suited to your specific needs. “For example, if Spanish is your first language and you have difficulty scheduling or attending pre-determined appointments, they can help you find a Spanish-speaking primary care physician that encourages walk-ins. Additionally, if you have to visit a cardiologist, but are not fond of rigorous medical exams, they can help you find one that avoids over-testing,” says Vivek Garipalli, CEO and co-founder of Clover Health. If you’re still puzzling over the differences in these two plans, here’s our quick-tips guide to understanding Medicare.

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Find state relief

Many states offer subsidies to help with medical costs for Medicare recipients below a certain economic threshold. However, there is no systemized process for applying, and you may have to reapply every year, says Garipalli. “Customer support specialists from your Medicare provider can help or provide you with additional information in considering these options.” Here are 10 secrets to lowering your medical bills.

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Realize you have some wiggle room

There are limited periods during the year when people can sign up, change, or leave a Medicare Advantage or Part D drug plan. However, many people are unaware of their options when they’re not in the open-enrollment period. Life-changing circumstances, such as moving, entering a skilled nursing facility, or losing coverage because a Medicare plan is no longer available, can allow you to make changes to coverage throughout the calendar year. “During a special enrollment period, people can switch from Original Medicare with a stand-alone Part D plan to a Medicare Advantage plan that includes Part D drug coverage at no extra cost and find savings,” says Zamosky. If you’re a caregiver of a Medicare patient, here’s a quick lesson in how Medicare works.

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Know the nuances

If you are a diabetic who uses a pump, it may be cheaper for you to get a Medicare Supplement Plan over a Medicare Advantage Plan. “Even though Medicare Supplement Plans have a monthly premium and Medicare Advantage Plans often do not, if you get the right Medicare Supplement Plan, your insulin could be covered at 100 percent,” says Kathe Kline, founder of MedicareQuick.com

Another reason to switch might be if your doctor administers medicine in the office: Again, under the Medicare Supplement Plans, your meds could be completely covered. “This happened with my husband when he was getting chemotherapy,” says Kline. “His treatments were covered at 100 percent and it didn’t cost us a dime. But it doesn’t stop with chemotherapy. Many, if not most, infusion treatments are covered by Medicare and will be covered by a Medicare Supplement Plan’s Part B coverage, whereas Medicare Advantage Plans will cover them under the drug portion of the plan, which could wind up costing a lot more money,” says Kline.

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Be mindful of your taxable income

Your Medicare Part B premiums are determined by your “modified adjusted gross income” from your taxes two years prior. That is, the amount of Medicare Part B premium you will pay for 2019 is based on the 2017 tax year (using the tax return you filed in 2018). Once you cross the baseline of $85,000 for a single person or $170,000 for a married couple (by even $1), you will incur additional Medicare Part B premiums—beginning at an additional $53.50 per month (per person) and scaling up from there. “So, controlling how much you take from your IRA (since all money taken from the IRA is taxed like ordinary income) versus other accounts will help save you from a nasty surprise a couple of years later,” says Victor Medina, founder of Medina Law Group. Here are 12 common budget mistakes to avoid in early retirement.

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Get help with prescriptions

Manufacturer’s Pharmaceutical Assistance Programs, sometimes called Patient Assistance Programs (PAPs), are an option to help Medicare beneficiaries lower their prescription drug costs—especially those who do not qualify for low-income programs (such as Extra Help). Pharmaceutical Assistance Programs are meant to lower the cost of brand-name prescriptions for Medicare beneficiaries who cannot afford the cost of their prescriptions. “There are also other non-profit foundations that offer PAPs. Many of these programs are specific to a medical condition rather than a prescription itself,” says Michael Stahl, CMO of HealthMarkets. Asking these 16 questions could save you money on medication.

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Be aware of what’s going away

Many Medicare Cost Plans will end this year in counties that have at least two competing Medicare Advantage plans that meet certain enrollment requirements. About 535,000 Cost Plan enrollees in 15 states and the District of Columbia will need to pick a new option. Medicare Cost Plans are hybrid plans with some of the features from both Medicare Advantage (MA) and Medicare Supplement (Medigap) plans. “Cost Plan enrollees may have to choose a new plan that best suits their needs,” says Stahl.

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Evaluate Medigap policies carefully

Most people opt for the least expensive monthly premium mainly when enrolling in a Medigap plan because the plans are standardized. For example, Plan F with one insurance company offers the same exact coverage as a Plan F with another insurance company, but the only difference between the two plans is the monthly premium. However, cheapest isn’t always best.

If the plan is an “attained-age” policy, the plan’s monthly premium will increase annually based on a percentage determined by the insurance company—and that can vary from year to year, points out Stahl.

Furthermore, if the plan offers an initial discount but that discount decreases with each year, the cost may climb to the point where beneficiaries are unable to afford their Medigap plan when they need it most.

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Understand the rules

“Generally, people turning 65 feel as though they must enroll in Medicare regardless of their other coverage, however, if someone is working for a large group (with over 20 employees,) they really do not need to do anything—as the group plan remains primary and Medicare will be secondary,” says Randy Frey, vice president of senior services at FNA Insurance Services.

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Know where to go for insider help

The best way for Medicare beneficiaries to find out significant Medicare information that is not easily accessible is to connect with a licensed insurance agent. Make sure you work with an agent who can show you all of your options, including Medicare Advantage, Medigap, and Prescription Drug Plans from multiple insurance companies. An agent should help beneficiaries assess their Medicare eligibility, find the right plan for them, and help them find out if they qualify for Low-Income Subsidy (Extra Help), as well as dual or other special needs plans.

Says Stahl, “An agent can also be a great resource whenever beneficiaries have questions about their coverage or when they need to make a change in the future. There’s no reason anyone should have to do this alone. Best of all, agents’ services are generally free.” Here’s why you’re probably overpaying for medicine.

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Anticipate changes in the Medicare Advantage Open Enrollment Period

Currently, during the Medicare Advantage Disenrollment Period (MADP), from January 1 to February 14, Medicare beneficiaries have the opportunity to disenroll from the Medicare Advantage plan they elected during AEP and can return back to Medicare with the option to enroll in a stand-alone Prescription Drug Plan. Due to the 21st Century Cures Act, the Medicare Advantage Disenrollment Period will be discontinued beginning in 2019, and in its place will be the Medicare Advantage Open Enrollment Period, which will be from January 1 to March 31 annually.

What’s that mean? During this time, Medicare beneficiaries will not only be allowed to disenroll from a Medicare Advantage plan and return to Medicare, but the beneficiaries are also given a one-time election to switch to another Medicare Advantage plan. Says Stahl, “This new Medicare Advantage Open Enrollment Period allows Medicare beneficiaries a period of time to be able to try out their current Medicare Advantage plan to see if it meets their needs in terms of provider network, prescription formulary, and overall benefits.”

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Look out for good news on the horizon

For 2019, Medicare Advantage plans have been cleared to exceed normal medical coverage to include supplemental benefits that make it easier for seniors to lead healthier, more independent lives. Lyndean Brick, president and CEO of The Advis Group, explains, “For example, people with asthma might like a plan that subsidizes their air conditioning, or helps underwrite healthy groceries, or provides rides to medical appointments, grab bars in the bathroom, etc. Pick your plan. Pick your perk. It might be eligible for coverage.” Don’t overlook these 18 secrets your health insurance company is keeping from you.