Steadfast Care Planning
Steadfast Care Planning is for people who want to learn how to best plan for their longevity including how to navigate extended care, long-term care insurance options, and other challenges that older adults face. Join Kelly Augspurger, Certified Senior Advisor (CSA)® and long-term care insurance specialist as she has thought-provoking conversations with industry professionals. Tune in as Kelly guides you on how to plan for care to live well.
Steadfast Care Planning
Demystifying Healthcare Options: Pre-65 Coverage and Medicare Planning with Cole Craven
Thinking about retiring before 65… but not sure what you’ll do for health insurance? 🤯
Cole Craven from Move Health joined me to unpack the biggest misunderstandings around pre-65 coverage, Medicare timing, and why “I’ll just let Medicare handle it” can lead to expensive surprises.
If you want clarity—not confusion—as you plan for the years before and after 65, this conversation will help you make smarter choices with confidence. Watch the full episode to learn more.
For additional information about Kelly, check her out on Linkedin or www.SteadfastAgents.com.
To explore your options for long-term care insurance, click here.
Steadfast Care Planning podcast is made possible by AMADA Senior Care and Steadfast Insurance LLC.
Come back next time for more helpful guidance!
Kelly Augspurger [00:00:02]:
Hey everyone, welcome to Steadfast Care Planning, where we plan for care to live well. I'm Kelly Augspurger, long-term care insurance specialist and your guide. With me today is Cole Craven, head of growth at Move Health. Thanks so much for joining me, Cole.
Cole Craven [00:00:16]:
Hey Kelly, thanks for having us. I'm excited to be here, talk a little bit about what we do, and bring some clarity to a increasingly opaque place: health insurance and Medicare.
Kelly Augspurger [00:00:25]:
That's it, and that's exactly what we're going to be diving into today. We're going to be talking about how to best navigate healthcare options for those those who are under 65 and then Medicare options for those who are 65 and older. So Cole, you ready to jump right in?
Cole Craven [00:00:39]:
Of course. Let's do it.
Kelly Augspurger [00:00:40]:
Okay. All right, well, let's start with the pre-65. So I know there are lots of options out there, Cole, and this can be very overwhelming for people, and I know you're going to break it down for us. So what kind of coverage options do people have between retirement and Medicare?
Cole Craven [00:00:56]:
Yeah, great question. This is really where we specialize at Move Health is within the kind of the early retiree sector. And part of my story and the reason we started Move Health to serve that group of people, is my in-laws were in this exact same situation. They were 59 years old, financially ready to retire, and they needed to solve one last thing before feeling comfortable and confident in their retirement plan. And that was, "What are we going to do for health coverage between 59 and 65 when I leave my job?"
Cole Craven [00:01:22]:
And so it's a huge question mark. There's 40 million people between 55 and 64 that are sitting in this exact scenario where they're saying, "I'd love to retire, but..." And so there are several options that are available to those that are retiring before the age of 65. And this is in really no order of priority. But as I kind of walk through each of those, the first one that we see most often leveraged by an early retiree is the Affordable Care Act Marketplace. The ACA Marketplace, also known as Obamacare, or just the Marketplace. This could be, they're federally facilitated like it is in most 38 states.
Cole Craven [00:01:57]:
There's also state based marketplaces like Covered California, or Kentucky Connect, or the New York State Health Exchange. You might also hear them referenced as exchange policies. This is probably 80% of the folks that we work with at Move Health, what they move to. The benefits of the Affordable Care Act Marketplace Coverages are guaranteed issue. So there's no medical underwriting. Your rates that you pay are based upon a couple of different things. The first one is your location. Second one is, in most cases, your age.
Cole Craven [00:02:23]:
The third one is going to be your income. And then the last one there is going to be if you are a tobacco user, or not. That's the only thing that the Affordable Care Act Marketplace plans can kind of rate you up or down on.
Cole Craven [00:02:34]:
The Affordable Care Act Marketplace was put into play in 2014. We'll talk about some things that are unique to the marketplace in regards to tax credits and things like that. That's why we see a lot of early retirees go this way. We'll talk a little more about that, Kelly, I think is part of the planned conversation. So that's Marketplace. That's one piece of the puzzle. Another one that we see leveraged often is COBRA.
Cole Craven [00:02:53]:
So COBRA, the thing that's important to note about COBRA is that it is a law, it is not a plan. So you don't go onto COBRA as an insurance carrier.
Cole Craven [00:03:02]:
COBRA is just your ability to continue your employer benefits. We'll talk a little bit more about that, I'll dive into that a little further. There's a couple other options. Obviously, if you have a spouse that's still working that has access to employer coverage, that's an option that you can leverage. Retiree benefits, pre-65. We see these on occasion with really large employers, but these plans are getting skinnier and skinnier as time goes on. Long gone are kind of the days of having a, "Oh, I've got a pension and health coverage for the rest of my life."
Cole Craven [00:03:28]:
That's kind of going by the wayside. And some of that's just because many people don't stay at an employer for 30 plus years any longer.
Kelly Augspurger [00:03:34]:
Very rare.
Cole Craven [00:03:36]:
Exactly. And so with that, we're seeing those plans kind of get skinnier and skinnier. So we've talked about the marketplace, we've talked about COBRA, we've talked about retiree plans. There's kind of two others that are out there. There's what we would consider off Marketplace health coverage. And so these might be health insurance plans that still have some form of underwriting associated with them. So they might ask about your height, weight, what prescriptions you take, and they might rate you up, or they could even deny you if there's things within that that look a little bit different, or maybe, the insurance carrier doesn't like.
Cole Craven [00:04:03]:
Important to note, many are time banded, so you can only hold them for a certain amount of time. Sometimes they're referenced as short-term health insurance, things along those lines. And so there's different unique regulations per state for each of those.
Cole Craven [00:04:14]:
And then the last one that is very niche, but that we see sometimes is healthcare sharing programs. And these would be things like Medi-Share, is kind of the biggest and largest in the space. This is not insurance, but it is a membership of other like-minded individuals that pay into basically a pool of member dollars and they use those to pay out of. The one we talk about often is Medi-Share because it acts a lot like insurance. Those are really unique. You should tread carefully there because there are ones that spin up that are brand new and there are ones that go away overnight.
Cole Craven [00:04:45]:
And so look for one that has stability and things along those lines in that space. And make sure you vet that with someone who is really well-versed in that space before making a decision on that. Not a cautionary tale, but rather just do your due diligence on anything that you decide to enroll to.
Kelly Augspurger [00:04:57]:
Yeah, well, quite a few options. So what's the best option for each person is probably going to be a little bit different. So, let's dig into COBRA. How long does COBRA last and what does it generally cost people?
Cole Craven [00:05:10]:
Yeah, good question. So in most cases, COBRA is going to last up to 18 months. From the point that you leave your employer, you no longer are eligible for your employer benefits. COBRA basically says if you are terminated, or if you retire or you quit your job, you have access to be able to say, "Hey, I want to still leverage that group benefit." But the caveat to COBRA is you can keep it for 18 months. But you are now going to pay 102% of the total premium for that plan. So when you are employed, typically your employer is paying a portion of your health insurance premium for you, on your behalf.
Cole Craven [00:05:50]:
Sometimes it's up to 100%. Many times it's 75, 80, 85, 90% of the premium the employer is paying on your behalf. And so you might pay $200, $300 a month for the plan, but the plan itself is actually $2,300 or $2,500 a month. Now, one, you take COBRA, you can stay on the plan, but you also have a 2% COBRA administrator fee that's tacked onto it. So you can keep it for 18 months, but you're paying 102% of the premium. So I think this year, 2025, the highest COBRA premium we have seen was for a family of 4. And it was just south of $5,000 a month is what they were paying. And we see these types of things happen all the time where someone says, "I think COBRA is probably my best option because I've got great coverage through my employer."
Cole Craven [00:06:35]:
And what they don't do is they don't look anywhere else. And so sometimes that results in them spending a lot of dollars that they maybe didn't have to.
Kelly Augspurger [00:06:41]:
That's insane. That's exorbitant.
Cole Craven [00:06:43]:
It is wild. But it also goes to show how big of a bill sometimes employers are footing on behalf of their employees.
Kelly Augspurger [00:06:50]:
Yeah. And they probably don't even realize it. Until it comes a time where that you're leaving your employer. Like, "Oh, maybe I had it pretty good after all."
Cole Craven [00:06:57]:
Yeah, exactly.
Kelly Augspurger [00:06:58]:
Well, Cole, how do COBRA premium rates compare to new hire, or marketplace plan rates?
Cole Craven [00:07:04]:
Yeah, good question. So the answer to that is, it depends. It depends on a couple of different things. COBRA is typically going to be the most expensive option available. If you are totally unsubsidized on the marketplace, we can talk a little bit about that. But if you're totally unsubsidized in the marketplace, there are times where it might be similar, times where we would tell someone to keep COBRA, or stay on COBRA would be if somebody is retiring mid-year and they maybe have met a maximum out-of-pocket, or they've met a deductible, or they're doing really big Roth conversions, or they had a business liquidity event, or they cashed out stock, or what have you, and they had a big high income year. We're going to say, "Hey, you're not going to qualify for any of those tax credits on the marketplace. Let's actually keep COBRA."
Cole Craven [00:07:49]:
You've met the deductible, you met a maximum out-of-pocket. Let's stick around with COBRA through the end of the year, and then we can review during the open enrollment period in what 2026 may look like. So there's times where that happens, as well, where COBRA can make sense even though it is expensive.
Kelly Augspurger [00:08:01]:
Okay, so household income obviously affects the subsidies.
Cole Craven [00:08:03]:
Bingo.
Kelly Augspurger [00:08:04]:
What about the special enrollment window if they lose their employer coverage?
Cole Craven [00:08:08]:
Yeah, great question. So, I think it's important to note, same thing for employer coverage, you have these things called "qualifying life events". So, one that happens while you're covered by an employer is if you have a baby, you can add that baby to the plan.
Cole Craven [00:08:23]:
If your spouse loses coverage through their job That's a loss of coverage. That's called a special enrollment period. Those are qualifying life events. And same thing for the marketplace specifically. You have to have a qualifying life event, a change of address, a change in employment, loss of coverage, adding or removing a dependent, adding or removing a spouse from coverage. You have to have something that's taking place in order to create a special enrollment period for the marketplace. There's only windows of time where you can get your employer coverage. It's also, I use the reference of you don't get into a car accident and then go buy your car insurance.
Cole Craven [00:09:00]:
That's why there's these things called special enrollment periods and why there's these things called open enrollment periods. Open enrollment period runs from November 1st through January 15th for the 2025 open enrollment period. And they have those open enrollment periods so you can't just join when you get sick. Same thing for the special enrollment periods. So the tax credits that we kind of referenced as well, Kelly, I think are important to hit on. So your household income, like I talked about, when we talked about the marketplace specifically income, can have a direct impact on what you pay for your health insurance. As a part of the Affordable Care Act that was written in the law in 2010, they said, "Hey, we're going to start this thing called the Marketplace, and it's going to be guaranteed issue." So there's lots of different private insurance carriers that are participating in the marketplace that are going to make certain that you can get a plan that is going to cover your preexisting condition, cover your preventive care, cover your prescriptions, cover your pregnancy, what have you. It's going to cover these 10 essential health benefits. But you have to be able to give it to everybody as long as they have a special enrollment period.
Cole Craven [00:09:56]:
And so you can imagine what, Kelly, you're in the space. You deal with underwriters and things along those lines and underwriting, when an actuary sees that they have to take everybody, what are we going to do? Premiums are going to fly upwards, right?
Kelly Augspurger [00:10:08]:
For sure.
Cole Craven [00:10:09]:
They're going to assume everybody's in the highest risk pool. And when they did that, they wrote this into law. They knew that that was going to happen. Premiums went up 300% overnight on the marketplace from December 31, 2013 to January 1, 2014. The Obama administration knew that would happen when they wrote the Affordable Care Act into law. And so they said, "We're going to create these things called advanced premium tax credits," which are federal tax subsidies that are paid directly to the insurance carrier that you choose on the marketplace based upon your income.
Cole Craven [00:10:36]:
And it's not looking backwards income, it is looking forwards income. So if someone is enrolling into health coverage during the open enrollment period for 2026, we're asking the question, what do you expect your income in 2026 to be?
Cole Craven [00:10:46]:
So you make your best estimate. It reconciles at tax time. But it's important to note those tax credits are available to people as they think about retirement. "How is my income coming to this equation? Why is this health insurance agent asking me about my income?" Because they're starting to bet, "Does it make sense if these tax credits come into play?"
Kelly Augspurger [00:11:03]:
Okay, well, clearly you're an expert in this, Cole. There's a lot of moving pieces and I'm so glad I'm not in the health insurance world. There's a lot of rules and regulations and laws and they change, right?
Cole Craven [00:11:15]:
They change all the time.
Kelly Augspurger [00:11:17]:
And so, keeping up with all of it. Oh, better you than I. The Steadfast Care Planning podcast is sponsored by AMADA Senior Care. AMADA provides complimentary consultation with a senior care advisor to find the right care from in-home caregiving to community care, as well as, long-term care insurance claim advocacy and unique support partnerships for financial advisors to address family transitions and generational retention. To learn more, visit: www.SteadfastWithAmada.com Tell us about network differences and benefit differences. What should people look for in marketplace plans when we're talking about network and benefit differences?
Cole Craven [00:12:00]:
Yeah, so that's probably one of the bigger changes that people experience when they transition to marketplace plans specifically. And it's also kind of one of those "gotchas" where a lot of marketing for plans that are off the marketplace and might have some weird exclusions and things like that, they kind of lean on. They go, "We've got a big PPO network," because everybody kind of hears, "I want a PPO," right? "I want a Preferred Provider Organization network." So that's what a PPO is. It means that you can go in-network, or you can go out-of-network. You're going to pay more if you go out-of-network. Typically, out-of-pocket maximums and deductibles double for out-of-network on PPO plans. And so that gives you flexibility.
Cole Craven [00:12:39]:
And so that's important. You also have to make certain it doesn't mean you can go everywhere because you still have to make certain that the provider, even if they're out-of-network, will actually bill the insurance.
Kelly Augspurger [00:12:47]:
Sure, yeah.
Cole Craven [00:12:49]:
Just because you can go out-of-network doesn't mean the doctor is going to accept it. So that's important. So PPO, a lot of people will say, "Hey, well, my job was PPO coverage. I could go anywhere I wanted." Okay, that's great. No worries. The marketplace, they're going to be more regional in that capacity.
Cole Craven [00:13:04]:
So they're going to be more of the EPO, the Exclusive Provider Organization, or HMO, Health Maintenance Organization. So the HMO, EPO, the differences, you should just note and make certain that your providers are in the network that you would like to participate in.
Cole Craven [00:13:19]:
And so each of those are going to have their unique drawbacks. If you said, "Hey, I'm dead-set on a PPO plan," well, you're going to pay a lot more for that. Or, I need to make certain these doctors are in network. Okay, let's take a look and make certain that they are. So you're likely to pay more for a PPO network. An HMO network is going to be less expensive, typically, but it's going to have more restrictions on what doctors you can see. You can't go out-of-network unless it's for emergency care, or you have prior authorization and it requires it. An HMO will require referrals to a specialist.
Cole Craven [00:13:47]:
An EPO is kind of like a hybrid between HMO and PPO. You've got kind of a regional network, but you're not going to require a referral to a specialist with an EPO. And so you just need to make certain when you are in that scenario, you're reviewing those things pre-65, whether it's the marketplace, or off-marketplace plans, or your new employer plan, what have you. Just make certain that your doctors are in the network. It's always best to have them in the network rather than trying to do gymnastics to make certain that you can get coverage for them, et cetera.
Kelly Augspurger [00:14:16]:
I would imagine those who have more complex medical issues...are you preferring more of a PPO, then? Because you have specific, maybe specialists that you work with and maybe you've been working with them for 5 or 10 years and you don't want to switch, so you want to continue. Do you find a lot of people do that?
Cole Craven [00:14:30]:
I think that there's a lot of people that have a preconceived notion that they need a PPO in that scenario, when in reality it's, 'Hey, I see several different specialists and I've worked with them for several years." California is an example. They're all in the Sutter Health Network. Okay, no problem. We can do that on an HMO. We can do that on an EPO.
Cole Craven [00:14:46]:
So it's just a matter of doing the review, making certain that the doctors and providers that you need to see are within the network of the plan that you want to choose.
Kelly Augspurger [00:14:52]:
Okay. So that's why it's probably really important to work with your healthcare agent, health insurance agent, and say, "Hey, this is exactly who I see. This is how often I see them. These are the medications I'm taking. My diagnosis is all of that." So they have all the info to be able to make that best recommendation.
Cole Craven [00:15:07]:
Bingo. And also why it's important to review things every year because doctors pull in and out of networks. And so, a lot of times we'll see big hospital networks bargaining with big insurance carriers and saying, "Hey, we're going to yank all of our doctors from taking your insurance if you don't give us these preferential rates, or what have you." So those are bummer situations where the people that are actually covered by the plan kind of become pawns in the negotiation scenario. But always important to review year-over-year that your providers are in network because plans change, networks change. Another thing that's kind of unique, Kelly, to insurance, health insurance, is that a provider, or an insurance carrier can pull in or out of a network at any time. So we've got an enrollment period where we can only change our plan at one point of the year, or with the special enrollment period.
Cole Craven [00:15:55]:
But a doctor, or a carrier can stop providing a network whenever they want.
Kelly Augspurger [00:16:00]:
Special privileges.
Cole Craven [00:16:03]:
Yeah. Bingo. Exactly right. It's something that is always changing. We're always navigating.
Kelly Augspurger [00:16:07]:
So what about preexisting conditions, Cole? How do preexisting conditions, or your current health status affect coverage and costs?
Cole Craven [00:16:14]:
Another good question. So on the marketplace, specifically ACA marketplace, where we see a lot of kind of that early retirees, just barely pre-65 group going...some of them have made it to that age without any preexisting conditions. And kudos to them, great job. Many didn't. And so maybe it's, "Hey, I take a statin, or I take so and so, or what have you, with that on the marketplace. The Affordable Care Act, as I said earlier, is guaranteed issue. It's guaranteed to cover your preexisting conditions. So if somebody comes to us and says, "Hey, I had a heart attack two years ago and I'm still seeing a cardiologist."
Cole Craven [00:16:43]:
We're going to say, "Okay, we're going to take anything that's medically underwritten just off the table," at that point.
Cole Craven [00:16:48]:
Because we don't want to have any exclusions or anything. We know you need coverage for that cardiologist. We're going to immediately start looking at the marketplace or COBRA. Because that's going to continue to cover that. So there's things like waiting periods, or things along those lines. In the marketplace, nothing like that. You could be undergoing current cancer treatment and infusions and all those things, and the marketplace is guaranteed to pick it up, given that you have a special enrollment period, or you enrolled during the open enrollment period.
Cole Craven [00:17:12]:
So preexisting conditions. It used to be prior to the Affordable Care Act, prior to 2014, someone would come to us and say, "Hey, I had a heart attack two years ago, and I still see a cardiologist quarterly." And we'd say, "Sorry, you can't get health insurance outside of a job."
Kelly Augspurger [00:17:27]:
It's so tough.
Cole Craven [00:17:27]:
And so it's made a big difference for that. But with that, again, costs went up because insurance carriers said, we're going to accept everybody on the marketplace.
Cole Craven [00:17:37]:
So, you can rely upon some of those tax credits, or things along those lines and leverage those. So hopefully that's helpful as far as preexisting conditions. There's a route for coverage. And what I tell somebody is never let health insurance kind of be the blocker. There's a lot of good reasons to not retire, but don't let health insurance be one of them because there's too many ways to figure it out.
Kelly Augspurger [00:17:55]:
Yeah. Obviously there's lots of options just based on what you shared with us.
Cole Craven [00:17:59]:
Bingo.
Kelly Augspurger [00:18:00]:
Yeah. Plenty to choose from. It's just what your situation is. It's going to then determine what the outcome is. So work with a specialist.
Cole Craven [00:18:07]:
Yeah. Rarely is it ever one size fits all.
Kelly Augspurger [00:18:10]:
No cookie cutter approach here. Yeah.
Cole Craven [00:18:12]:
Bingo.
Kelly Augspurger [00:18:13]:
Cool. Okay. Learned a lot. The under 65. Now let's pivot to 65 and up. So we're talking about those people that are trying to get on Medicare. What do people 65+ need to know about Medicare to avoid late enrollment penalties? Let's start there.
Cole Craven [00:18:28]:
Yeah so, we can start with late enrollment penalties. That's great. LEPs as we reference them. I think that that there's a lot of EPs that happen within Medicare. But one other thing that's important is, I'm glad, Kelly, and I know you know a lot. You're in the insurance space. There are so many times that we hear someone say, "Well, I'm going to turn 65 and I'm going to get Medicaid."
Cole Craven [00:18:46]:
You're like, "Okay, hold on, hold on, pause." So just very high level, Medicaid is for typically lower income individuals. It's typically a state based program. So you can remember Medicaid. We aid people that need help. We aid people that are typically it's under the age of 65 that people get Medicaid.
Cole Craven [00:19:06]:
You can have points where Medicare and Medicaid coordinate, but Medicaid is state based health insurance for lower income individuals, typically.
Cole Craven [00:19:13]:
Medicare, we care for the older people in our society. So Medicare is for those that are 65 and up or have become disabled prior to 65. And so as we think about initial enrollment periods, special enrollment periods for Medicare, I always say it's our God given right to, whatever it is...life, death, taxes and getting lots of mailers in regards to your Medicare.
Kelly Augspurger [00:19:33]:
So many.
Cole Craven [00:19:34]:
So, Kelly, I don't know, how old your parents are. If they're at that point where they've made...it's like, "Holy-Moly." My mom turned 65. She turned 65 this January and it's like the amount of mail that she is receiving daily.
Cole Craven [00:19:48]:
Is crazy. So, it's important to start making some of those decisions. 64 and a half to start getting to a point and saying, "Okay, I need to be thinking about Medicare at 65." Even if you continue to work past 65, there are still some considerations. So a late enrollment penalty. As you talked about, Kelly, that happens when you don't apply for Medicare when you should. So you can avoid late enrollment penalties by checking in at 65 with someone who can help you with your Medicare to say, "Do I need to enroll into Medicare at 65?" Typically many people are going to take Medicare Part A. Medicare Part A, that's the part that you've paid for your entire career.
Cole Craven [00:20:26]:
Or your spouse is paid into, depending on what type of work you did, whether it was in the home, or out of the home. If you worked your 40 quarters, or your spouse worked there 40 quarters, you're going to get Medicare Part A for free. That's the hospitalization portion. Medicare Part B and Part D are where the late enrollment penalties can come into play. And it basically means if you didn't enroll for Medicare Part B when you should have. And so that could be when you turn 65, or when you leave creditable employer coverage that you could incur those. And so it's just important to note, is your group employer plan creditable coverage?
Cole Craven [00:20:57]:
Do you have 20 plus benefits, eligible employees, et cetera? There's all kinds of things that kind of go into that mixture. But if you are turning 65, just review Medicare with someone.
Cole Craven [00:21:08]:
Make certain that you have an understanding of what's coming, what's next to avoid those late enrollment penalties. Typically, those are going to be fairly low cost if you let it go a couple of months. And usually they're not even going to start assessing those until you've gone 6 months, or more, where you're Medicare eligible and not enrolled. The biggest one I've seen recently was, an advisor partner of ours reached out and said, "Hey, we've got a client who we just found out hasn't enrolled in Medicare and they're 7 years past their eligibility."
Kelly Augspurger [00:21:34]:
Oh, no. Oh, Gosh.
Cole Craven [00:21:35]:
And the thing about late enrollment penalties is, the bummer about them is the late enrollment penalty on part D and part B is they never go away. You don't get to pay them off. They just stick around forever. And so important to make certain you review and understand what those are.
Kelly Augspurger [00:21:49]:
No kidding.
Cole Craven [00:21:50]:
You only get those if you should be on Medicare and you don't have creditable coverage elsewhere. So typically that's going to be if you don't have employer coverage and you're 65 or older, you need to be on Medicare.
Kelly Augspurger [00:21:58]:
And you can even start looking at it before 65. Is it 3 months, Cole?
Cole Craven [00:22:02]:
Yeah. So the initial enrollment period, I think, is what you're referencing, Kelly. If you are not intending to work past 65 and continue to have employer coverage, or your spouse has employer coverage that you can be on, you can start actually enrolling for Medicare parts A and B, 3 months before your 65th birthday or 3 months after. So you've got a six month window that's called your IEP or your Initial Enrollment Period. And so that's when you can do that. If you work past 65, you've got 8 months after your creditable coverage ends to enroll into part A and B. And like I said, most people will take part A because it's free. If you're taking any part of Social Security, if you're already taking that at 65, you're going to get Medicare Part A and you have to defer Part B unless you want to take it.
Cole Craven [00:22:46]:
Part B the reason sometimes people will defer it is it's the portion that you have to pay for. There's a monthly premium for Part B. So hopefully that answers your question on initial enrollment periods.
Kelly Augspurger [00:22:55]:
It does. Can we talk about what each part of Medicare covers and what people could potentially expect to pay out-of-pocket? I mean, you already referenced A, hospital B, we know is medical, D, prescription drugs. We haven't talked about Part C, Advantage plans. What can people expect, standard premiums, deductibles, coinsurance amounts. How do they vary? What could people expect?
Cole Craven [00:23:15]:
Yeah. So it's going to depend on a couple of different things, but there's a few that we can count on. So we know that Medicare Part A, like I mentioned, if you worked your 40 quarters, or your spouse worked 40 quarters that you can draw on, you're good. You're not going to pay anything for Medicare Part A. That's the hospital portion. The way that some of our team references it as is, if you're in the hospital, it's the bed that you're laying in, it's the jello on your plate, and it's the nurse that brought it to you.
Cole Craven [00:23:37]:
So, yeah, that's one way we hear Medicare Part A referenced is it's hospitalization. Yeah. Medicare Part B, it doesn't make any sense, but it is medical. So this is doctor's visits. These are outpatient surgeries, things along those lines.
Cole Craven [00:23:51]:
Surgical. Anything that you have done in a doctor's office is going to be subject to Medicare Part B. And so that's that portion of it. Durable medical equipment falls into that, as well. So that's Medicare Part B. Medicare Part B has a premium.
Cole Craven [00:24:04]:
And so this is one of those ones that's pretty standard. The standard Medicare Part B premium in 2025 is $185 per month.
Cole Craven [00:24:12]:
So you start Medicare Part B, you're going to start paying $185 per month.
Kelly Augspurger [00:24:17]:
Cole, do you know 2026 now? We're recording in 2025, but I believe this is going to air in 2026, is it going to be slightly inflated?
Cole Craven [00:24:24]:
Typically, yes.
Cole Craven [00:24:26]:
Typically the premiums will go up for Part B every year, as an example, in 2024. So we don't have 2026 numbers, yet. 2024, the standard Part B premium was $174 per month and it went to $185. 2023 was funky. That Medicare Part B premium actually went down. Don't count on that. That's very rare.
Cole Craven [00:24:48]:
There was some legislation that took place at that point that caused that. If we had to make a guess, we're probably going to see part B premiums, around $190 range moving into 2026. But don't quote me on that because it is to be determined. That rolls out a little later in the year. So that's the part B. The way that Part B is paid, if you're drawing Social Security, it's going to come directly out of your Social Security check.
Cole Craven [00:25:11]:
If you are not drawing Social Security, you're typically billed monthly for it. So you're billed, you can send in a check to Medicare if you have IRMAA applied, which is the Income Related Monthly Adjustment Amount. If you are high income related earner, I don't want to get too far into the weeds, you're billed quarterly.
Cole Craven [00:25:24]:
So there's all kinds of different ways, but you have to pay for part B. Medicare Part D, as in drug, it's the only one that makes sense is prescription drug coverage. Yeah, we can talk a little more about that because that's an important one that someone should review annually. And then Medicare Part C, I always reference that one last, Medicare Part C is Medicare Advantage. This was rolled out in 2006. This is something where you're going to have all of your Medicare benefits, A, B and D smushed into one.
Cole Craven [00:25:52]:
The benefit of a Medicare Advantage plan is that it's all smushed into one. There's sometimes extra benefits like dental and vision and over the counter drug benefits that you can use at the pharmacy or things along those lines that are included in a Medicare Advantage plan. Maybe one of the drawbacks is traditional Medicare parts A and B, they operate on an open network. If your doctor takes Medicare, you can go there. And typically Medicare parts A and B and traditional Medicare, you pair it with a Medicare supplement and a drug plan, a standalone drug plan. We'll talk more about that. Medicare Advantage takes all those things and mushes them together. And so when they do that, they mush them all together under one carrier.
Cole Craven [00:26:24]:
Or under a carrier that you choose. And then you've reintroduced a network. So you've reintroduced a network into that. Meaning the insurance carrier that you choose your Medicare Advantage plan through is going to tell you what doctors you can see what doctors you can't see. And sometimes it can come with a actual higher annual exposure possibility. There's a maximum out-of-pocket, there's co-pays, there's deductibles you need to hit on a Medicare Advantage plan, whereas on a Medicare supplement, if you went the Medigap, or Medicare supplement route, you're going to have, typically you're going to have a premium that you pay for it per month.
Cole Craven [00:26:53]:
But that being said, your annual exposure is going to be much lower, typically. So you've got two kind of choices. Medicare supplement, traditional Medicare with a supplement, or Medicare Advantage, the pros of a Medicare supplement and traditional Medicare: wide open network. The con of it, you have to pay for it. So you've got to pay for your part B premium and your Medicare supplement and a drug plan, but it offers the most flexibility. Medicare Advantage typically premium free, typically $0, you're still going to pay your Medicare part B premium, typically premium free for the Medicare Advantage plan itself, but you're going to have networks reintroduced and you've got an insurance carrier that's now administrating your Medicare on your behalf.
Kelly Augspurger [00:27:29]:
The Steadfast Care Planning podcast is sponsored by the Certification for Long-Term Care, CLTC, an in-depth training program that gives financial advisors the education and tools they need to discuss extended care planning with their clients. Look for the CLTC designation when choosing an advisor. If you're looking to become a CLTC, enroll in their masterclass and enter "Kelly" in the coupon code field for $200 off. So we just talked about the pros and the cons with Medicare Advantage and then just traditional. What about Medigap, we've heard Medigap, that term. What does that mean, Cole?
Cole Craven [00:28:07]:
Yeah, good question. So traditional Medicare, if we go back to it, Part A, hospital, Part B, medical, Part D, drugs. Parts A and B, traditional Medicare, it's going to cover 80% of your costs and then there's just 20%. What do we call it? A gap. This 20% gap and so aptly named the Medigap plan is going to come in secondary to your Medicare. As we think about order of payors in health insurance, we could get really heady and talk about all these things. But in order of payors, Medicare is going to be your primary payor and then your Medigap plan would be secondary and that's going to come in and swoop in and take care of that 20%.
Kelly Augspurger [00:28:44]:
So really, Medigap and supplement plans are synonymous.
Cole Craven [00:28:48]:
They are the exact same thing.
Kelly Augspurger [00:28:49]:
We're just using different words. There are a lot of acronyms, a lot of words in the health insurance industry. And if you've ever looked at your paperwork, your bills from your doctors, there are probably codes and words on there that you're not familiar with, so Medigap equals supplement.
Cole Craven [00:29:06]:
They are the exact same thing. So a Medicare supplement is going to work with original Medicare and it's going to fill that gap. So that's what Medigap does. There are varying levels of Medigap, or Medicare supplement plans, that you can choose A through N, not to give you more letters, but they're Medicare supplement plans A through N. The most comprehensive that's available to Medicare beneficiaries right now that are turning 65, or enrolling into Medicare, is typically a Medicare supplement Plan G. And that Plan G is going to reduce your out-of-pocket exposure to $257 a year.
Cole Craven [00:29:39]:
So you're just subject to the Part B deductible.
Cole Craven [00:29:42]:
You might hear some people reference plan F that no longer is available to people that were not Medicare eligible prior to 2020. And so you can't get a plan F. But that covered everything. So that would say we're going to go through the entire column of things. All the co-pays, all the excess charges, international travel, all those things, including the Part B deductible. But now Plan G is kind of the highest and most comprehensive supplement that's available out there.
Kelly Augspurger [00:30:03]:
G is great. I'm going to go with that. G is great.
Cole Craven [00:30:06]:
G is good. F is fantastic, G is good, but you can't get F anymore.
Kelly Augspurger [00:30:11]:
Gosh, can't get the fantastic anymore. Just the good.
Cole Craven [00:30:12]:
That's right.
Kelly Augspurger [00:30:14]:
Well, let's briefly talk about prescription drugs. Cole, how do these like standalone Part D plans differ from Advantage plans that include the drug coverage? What does that look like?
Cole Craven [00:30:24]:
Yep. So if we think about traditional Medicare, typically someone who goes traditional Medicare, they're going to have parts A, B, they're going to have a Medicare supplement that's going to fill the 20% gap. And then they're also going to have to carry prescription drug coverage. So that's Part D. Part D for drugs. A Part D prescription drug plan is going to be purchased through a private insurance carrier. Ones that are big in this space are Wellcare, or Aetna, things along those lines.
Cole Craven [00:30:51]:
United Healthcare, AARP, those are big ones that are in the prescription drug plan space. That being said, you purchase these, they're typically very low cost. Sometimes they have zero premium. And what they will do is it's going to be coverage specifically for your prescription drugs. So when you go to the pharmacy, you're going to give them, if you're on a traditional Medicare with a Part D prescription drug plan, you're going to give them your Part D coverage and that's what they'll use to bill against on that side. Medicare Advantage, like I mentioned, it ropes all of those things into your Medicare Advantage plan. Typically, a Medicare Advantage plan is going to include prescription drug coverage.
Cole Craven [00:31:24]:
And so with that, you need to make certain that the drugs that you take are included on the prescription drug plan. Whether that's included on a Medicare Advantage plan or standalone, you need to make certain the specific drugs that you take are on the formulary for that plan.
Kelly Augspurger [00:31:35]:
So review every year. Right, review every year.
Cole Craven [00:31:38]:
Because again, formularies change.
Kelly Augspurger [00:31:40]:
Sure.
Cole Craven [00:31:41]:
Prescription drug plans change. Insurance carriers are always looking for ways to reduce their costs. There's legislation recently that did some things with the donut hole that I can talk about here in a moment.
Kelly Augspurger [00:31:50]:
That was my next question. What about the donut hole? What's that coverage gap?
Cole Craven [00:31:55]:
So there was, prior to 2025, there was this thing called the "donut hole" that said you're going to enter a catastrophic phase, you're going to have to pay. And it was this really intense coordination between what the beneficiary pays and what the insurance carrier pays and what Medicare pays. And you hit the point where the drug plan would pay, the drug plan would pay, and then they would just stop for a portion of time. And then you were responsible for the full cost of the drug.
Kelly Augspurger [00:32:20]:
Can't even imagine.
Cole Craven [00:32:21]:
The donut hole is now gone. So the way that I explain this to people is I talk about my neighbor. My neighbor was previously on some very high dollar, non-generic brand name prescription drugs and they were spending between $10K and $12K a year. And they were hitting the donut hole in like February, or March. And they were paying a lot throughout the year. And at the end of the year, their drug costs kind of tailed off because the drug plan started to pick back up.
Cole Craven [00:32:45]:
Now there was legislation in 2024 that was passed that in 2025 removed the donut hole and said a beneficiary on a prescription drug plan will pay no more than $2,000 a year on their prescription drug costs. And so for my neighbor, they went from spending $10K to $12K a year to this year spending $2,000.
Kelly Augspurger [00:33:04]:
Amazing. I'm sure they're relieved.
Cole Craven [00:33:05]:
Yeah, that's a huge thing. So the donut hole is now gone. The downside of that is we saw prescription drug plans kind of tick up in cost, especially ones that have those brand name prescription drugs. We also saw formularies get skinnier, too.
Cole Craven [00:33:19]:
So that's important.
Kelly Augspurger [00:33:20]:
Okay. And remind us about the Annual Election Period, the dates there, and then any Special Enrollments. What are those dates, Cole?
Cole Craven [00:33:27]:
Yeah, so the Annual Election Period, AEP for Medicare runs from October 15th through December the 7th. And this is your time of year to review. If you're on original Medicare with a Medigap, or a Medicare supplement. We know those are synonymous now. And a prescription drug plan, typically you're not going to make changes to your Medigap plan. What we say at Move Health is we hope that this is a lifelong relationship that you have with this insurance carrier and yourself. We're not typically going to make changes to a Medicare supplement. We will, however, review and make changes to your prescription drug coverage.
Cole Craven [00:33:58]:
So Part D, you review this every year during the Annual Election Period. Don't set it and forget it because you might get surprised. You might take a new prescription drug that you need to make certain is covered on the Medicare side of things. So review that between October 15th and December 7th. So that's what happens for Part D. You can review that, make changes that will go effective January 1st of the year following. And then this is also the time, if you are on a Medicare Advantage plan, this is your time to review Medicare Advantage plans and make a change for something that would start during the beginning of the year.
Kelly Augspurger [00:34:25]:
So they can switch if they need, if they want to.
Cole Craven [00:34:27]:
Yep, because again, on Medicare Advantage you have networks that change, you have co-pays that change, you have plans that change. You'll have carriers that pull in and out of zip codes and things along those lines. So always important to review.
Kelly Augspurger [00:34:38]:
But can an Advantage member, can they switch to traditional Medicare, or no? They can, but they have to go through underwriting. What does that look like?
Cole Craven [00:34:46]:
Yeah. So if we wanted to go from, if we were on a Medicare Advantage plan, and this doesn't necessarily have to happen during the Open Enrollment Period, Annual Election Period. But if somebody wanted to go from a Medicare Advantage plan to a Medicare supplement, in most states, you cannot do that without having to go through underwriting to get the supplement. There is a portion of time, your Initial Enrollment Period, where you can get a Medicare supplement with no underwriting. So this is why it's important to make these Medicare decisions from the jump, because you can always, this is what I say:
Cole Craven [00:35:18]:
You can always go from a Medicare supplement to an Advantage plan. You can't always come back.
Cole Craven [00:35:24]:
And so it's important to make that decision from the jump. It's always easier. What's that parenting reference, Kelly, where it's like you can...it's easier to loosen the reins than it is to tighten them back up.
Kelly Augspurger [00:35:33]:
For sure. Yeah.
Cole Craven [00:35:34]:
From that perspective, you may want to look at a Medicare supplement first just to reserve your right to keep that and to have it in a guaranteed issue format as opposed to going Medicare Advantage right when you turn 65. You can always go that direction. You can't always go back. There are some states that have rules where you can make a switch to a Medicare supplement whenever you'd like to with no underwriting. But again, premiums go up for those like crazy. Those are states like New York and Washington state that have rules like that. So typically though, you can't go from Medicare Advantage to a Medicare supplement without medical underwriting.
Kelly Augspurger [00:36:08]:
Great advice and really important that people do their due diligence upfront before selecting a plan. So if you know someone that's almost 65 and they're about to do all this research, make sure they're working with someone and making hopefully that right decision from the get go. A lot of really great advice here, Cole. I would be remiss if I didn't, as a long-term care specialist, talk about briefly, Medicare. Do you often see that people believe that Medicare is going to cover their long-term care costs, their extended care costs?
Cole Craven [00:36:37]:
Oh, Kelly...
Kelly Augspurger [00:36:39]:
We can spend probably a. whole episode on this, but this is common, right?
Cole Craven [00:36:42]:
We definitely could. There are a lot of preconceived notions on what Medicare is going to do. And I know before when we were even talked, when we first met, Kelly, it's something we talked about. There's a preconceived notion out there that Medicare is going to cover their time in a nursing home, long-term, or things along those lines. That's just not, that's not the case. Don't rely on Medicare for that. There are small pieces that Medicare will come in and pick up, but do not count on it.
Kelly Augspurger [00:37:06]:
Yeah. Well, I'm glad we talked about that. I feel better about it. But that's true. We're not counting on Medicare to cover our non-medical ongoing needs that we have, whether it's at home, or in a facility. And then Cole, any final advice on how people can plan for care to live well?
Cole Craven [00:37:21]:
Yeah, that's a big question, but I think the biggest thing is is is making certain that you are informed and empowered around your healthcare decisions. Kelly, whether that's around your long-term care plans, or that is around what your health insurance, or Medicare plan is going to be moving into the next year. Be sober about these decisions because it is a multi thousand dollar a year cash flow decision that you are making and make certain that whoever you are making that decision with, or alongside, or whoever's opinions or advice you are bringing into the equation is truly working within your best interest and taking into account, your income, and taking into account your goals, and do you travel, and where do you live and all these things that are a big piece of why and how you choose medical coverage. Make certain that you are informed and empowered around that. And this is not an infomercial for what we do at Move Health. But that is one of our goals is to create informed and empowered healthcare consumers. So the way that I break that down to most common denominator is I say, "We want people to leave an experience with us knowing how much it's going to cost when they go to the doctor."
Cole Craven [00:38:23]:
Because I think if you asked a majority of people in America what's it going to cost when you go to the doctor's office, they're going to say, no idea, I don't know, I just kind of go and then pray that the bill's not crazy.
Cole Craven [00:38:35]:
And how do you advocate for yourself in those scenarios of like, "Do I really need that part? Like I see this blood panel, do I need that in there, or is this just preventive?" or what have you. Because those are all going to be built differently. And many times a provider is not doing it to get more dollars out of you, they're doing it because they care about you in that instance. But in the same respect, make certain you understand how much it's going to be when you go to the doctor's office. So just be informed, be empowered, do your research. Health insurance and Medicare are riddled with personal bias of people's experience. So if you have the opportunity to talk to an objective 3rd party that's going to say, "Hey, here's truly what's best for you, sure your cousin may have had a bad experience with (insert name of carrier), but that was because of of X, Y and Z," or what have you, at the end of the day. You know this, Kelly, as well: insurance is a contract.
Cole Craven [00:39:20]:
And the carrier is beholden to that contract and the covered beneficiary is beholden to that contract. And so whatever happens in that contract is what will happen. And so just need to be able to understand it.
Kelly Augspurger [00:39:30]:
And as a 3rd party objective, that's you, Move Health, right? How can people find more about you and Move Health and your services, Cole?
Cole Craven [00:39:38]:
Typically the way that we work is we work with a financial advisor and their client. That's typically how we work with 90% of our clients. They're going to come to us through their financial planner. That being said, we do know that there's some times where someone wants to come to us directly. Easy to find us in the show notes. Kelly, I think you'll post some links that'll be in there so you can find us there. But yeah, so easy to find us online, MoveHealth.io if you're an advisor, there's a link for you to go to.
Cole Craven [00:40:00]:
If you're someone who maybe just wants our help, don't be offended when we ask who your financial advisor is, that is something that we will do. That's how to get a hold of us. And the thing is, once again, not an infomercial for us. Just make certain you are talking to a strong, objective 3rd party that's going to come in and genuinely...if you are in a conversation about health coverage, or any type of insurance, or financial service, or what have you, if there's any point where you are feeling pressured to go one direction or another, just review that. Make certain you feel good about whatever decision you're making. And don't forget about important dates.
Kelly Augspurger [00:40:30]:
Yes, mark your calendar.
Cole Craven [00:40:32]:
Make certain you take care of it and just get it done early. We see it all the time, people procrastinate to the last minute. Just get it done early. Don't make it a stressful point for yourself.
Cole Craven [00:40:40]:
It doesn't have to take a long time.
Kelly Augspurger [00:40:42]:
So yeah, don't procrastinate. Well, Cole, thanks so much. You provided us a lot of really helpful info today. I know it was a lot to digest, but I think people learned a lot. I certainly learned some new things. So really appreciate your time and your expertise.
Cole Craven [00:40:54]:
Of course.
Kelly Augspurger [00:40:55]:
Have a wonderful day.
Cole Craven [00:40:56]:
Thank you, Kelly. Thanks for having me. All right, bye bye.
