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The team at MedicareSchool.com led by Marvin Musick answers REAL Medicare questions from our callers, and help bring clarity to the VERY confusing Medicare System.
Medicare School Daily
The 2 Most COMMON Ways To Get Stuck With A Medicare IRMAA | April 22nd, 2026
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A lot of people don’t find out about IRMAA until their Medicare premium suddenly jumps — and by then, the damage is already done.
On today’s Medicare School Daily, we’re digging into the two most common situations that can trigger these higher costs, and why they catch so many people by surprise. If you’ve ever made a financial move and thought, “there’s no way this affects my Medicare”… this is the episode to pay attention to.
We’ll unpack how these scenarios actually happen, what to watch for ahead of time, and where people often get caught off guard.
📞 As always, the phones are open — so if you’ve got a question about your situation, call in and we’ll walk through it with you live.
Well, we want to welcome you to uh Medicare School Daily. I have uh with me in the studio one of our great agents. Um Evan Cruz uh does a wonderful job, been with us for a long time now, and he's joining uh with me today, and we're excited to be with you and excited to take your questions. Uh let me just give you the call in line because we'd love to hear from you today. Uh the number is 833-824-2004. 833-824-2004. Now we're going to be talking about ERMIS, but whatever is on your heart and your mind, you can call in today and we'll be uh happy to at least try to help. Uh, usually we can answer the questions. We'll certainly do our best to give you some uh clear direction, uh, whether it relates to Medicare or Social Security or really anything investment-wise, uh, we're happy to deal with today. So we are thrilled to have you with us today. Uh, let's get into our topic. Let's talk about ERMIS. So, first off, ERMAS. Uh let's def let's uh uh define that acronym ERMA. It uh stands for Income Related Monthly Adjustment Amount. And so it's kind of a mouthful. Uh and so the ERMIS, I think, uh actually started uh back in um uh the days when Obamacare was passed, uh, the Affordable Care Act. I'm pretty sure that's when it was. It may have been before that, but uh I think that's when it was. If not, it's been around for a while. Uh and this is an issue that those of you that are high income are gonna have to deal with. Uh and sometimes that high income could have been uh uh previous high income, not just presently. So we're gonna get into the details of IRMA. Uh the title of really our show today is the the two most common ways to get stuck with an IRMA. No one will get gets stuck with an IRMA, but you may. And so we're gonna we're gonna discuss that. So uh first off, get let's give them the definition again of the IRMA. What's the acronym stand for?
SPEAKER_00Income related monthly adjustment amounts.
SPEAKER_01All right. Sounds good. And so uh when it comes to IRMA, uh I'm gonna let you explain, Evan, because you know how this works. But uh let's talk about um uh the the the financial numbers that really determine uh wh whether we're gonna pay an IRMA or not. So kind of explain that whole formula and that system, and then we'll kind of dialogue more about that.
SPEAKER_00Absolutely. So the the obviously why why why an IRMA? Why does that exist to begin with? And so it's usually it's people who make more money is designed to pay more money into the system because the system is built in such a way that it everyone kind of needs to pay their share. That's kind of the the idea behind IRMA. And so you're if you're making more money, you're gonna pay more money, but that doesn't mean that uh you're just gonna stay that way. That your incomes change, your financial situations change, and sometimes they don't, in which case, you're doing great. Keep doing what you're doing. If you're earning more money, I always tell people, then uh don't change a thing. Uh congratulations, yeah, you'll pay more in Medicare. But great problem to have. It's a great problem to have. Who cares? You're making more money. That's the point of the system, absolutely. And so the way it's designed is there are different tiers, different brackets of how much it is you earn, and it's based on either your filing income individually or filing as a married couple, filing jointly, or a married couple filing individually. It's uh everybody's a little bit different in how they file their taxes, but ultimately it based on how much you make is how much you're ultimately going to be paying. And as time goes on, they're always doing that two-year look back. So they are strictly with blinders on, only this year it's 2026, looking back at 2024, and that's all they look at. And they look at the number. They don't even necessarily look at how you got to that number. They just look at the base number and they assume that that's what you made last year, this year, next year, and every year for the rest of your life until you tell them otherwise. So it's very important to infer to the A.
SPEAKER_01So 2026, looking back at 2024, what are they looking back at?
SPEAKER_00They're looking back at your modified adjusted gross income, the total amount that you earned, not just your earned income from your job, but anything that you're getting from um IRAs or 401k distributions or selling a house or anything and everything that shows up on that line, that modified adjusted gross income line, and that is a total number. That's what they're looking at, and that's what they're gonna be varying, and then that's what they're like, they're gonna be assuming that that's what you're making this year. And they rely on you to tell them it's not that case if it's changed.
SPEAKER_01Yeah, exactly right. So uh just so you know, that's line 11, AGI, and uh what um Evan is saying is correct, all the income that's uh subject to tax is gonna be there. Uh and then they're gonna add line in uh line two A. Uh most people don't have anything on line two A, but it is tax exempt interest. So if you're an investor in municipal bonds uh or um uh I don't think they call it like foreign national bonds, uh those are uh not federally taxed, but you still have to report that on your return, line two A. So if you're curious to know what your modified adjuster gross income is, look at your uh tax return. Uh again, 2026, they look at 2024, line 11 plus line 2a. And so if that will be above the thresholds, then you're going to have an IRMA. Uh and as he said, it's a great problem to have. It's annoying, uh, but it's still kind of the way Medicare is going to work. And remember, uh, these numbers are recalculated every single year. So next year, 2027, looking at 2025. Uh the money we're making this year will not matter until 2028. Um so that's the system. Uh so those of you that are high income, let's just talk about let's just talk about not all the thresholds for sure, but let's deal with the with the with the with the um the baseline. Sure. So uh the single, let's uh deal with single filers and then married filing a joint return. What are those numbers this year?
SPEAKER_00Sure. So just the first two lines there. So you know if you're under 109,000 uh or less as single as a single person or single filer, you're gonna be looking at the same 2029 for Medicare Part B and no additional cost of your prescription drug plan Medicare Part D. It's gonna be the base of whatever that plan is that you're on. And no ERMA. No IRMAs, yeah, no additional cost to those. Um is a married couple filing jointly, it's 218,000. And then anything uh once again, that or less, and then then no additional cost on B or D on that one either. Um just one bracket up, which is usually where some people kind of fall in that line where it's just over. That's usually probably the most common ERMA, I would say, is just over the line. And that's it's only about $81 or so more. It's it's very, very it's not a a earth-shattering amount of money more. Um so it's not gonna double it. That's the next bracket up or doubles it. But it's uh it's only about about a 30, what is it, 2022 is gonna be 219 to 236.
SPEAKER_01I've got uh yeah, uh a single uh filer would be 109 to 137. Uh-huh. Uh a married following joint return, that first Irma level is two eighteen to two seventy-four.
SPEAKER_00Yeah, they got a lot bigger than that. Yeah, yeah, exactly. I usually look in straight at the numbers and have that right in front of me. Yeah, so it's a pr on a pretty big window of time there or window window of space there, but it's not that much money. I mean, eighty-one dollars, yeah, it's not fun to pay that additionally. Um and usually, like I said, there's when you're on that line, usually you have just retired or it was a one-off situation that you were finishing up that year, a couple years before. And so that's where it comes into letting them know and getting it taken off. Right.
SPEAKER_01And then making it. Let's talk about that. But before we do, though, let's remind everyone that if you have that high income, not only do you pay more for B, but you also pay more for your drug plan as well. Uh and so the that that first level of IRMA on the drug plan is $14.50. So what he's saying is you have $81 extra on the B, $14.50 extra on the D. So someone in that income bracket would have a $95 total IRMA. Um and so then, of course, they just keep going up from there. Right. All right. And so uh as we discuss this whole idea of IRMA, uh, Evan was saying that uh this may happen because you just retired, but sometimes people, their income continues to stay up and they pay IRMAS their whole life, which is truly a great problem to have. But what we want to talk about today during our segment here is to make sure everyone knows that there's really two common ways that people get stuck with an IRMA that would just be somewhat out of the ordinary. All right. And so let's deal with that first one uh would be uh people not realizing that all the income is going to count. So we'll have people I had a guy not long ago that uh uh his uh daughter had a very expensive wedding and uh pulled a sizable amount of money out of his uh IRA. Uh and of course that's now reportable income, and that pushed him into the IRMA. That just did. And so if someone's going to do a Roth conversion or any kind of a, you know, uh uh a large withdrawal from IRA or 401k plan, that is going to show up. And so your income by itself may have been below uh the threshold. But when you did that withdrawal, now it pushes you into uh, you know, the the IRMA bracket. All right. And so that is one common way, not realizing all income is going to count the second one, is when people don't realize uh that they're gonna get an IRMA and they don't appeal an IRMA, right? And so that's how they get stuck. And so um let's let's let's walk through the whole process. Someone applies for Medicare, uh, they're notified that they're uh uh going to pay a certain amount for their Part B premium, so they they get this IRMA letter. And so when the IRMA letter comes, what should they then do?
SPEAKER_00Yeah. So that's and that's what you're looking for. Because there's really nothing you can do until that letter shows up in your mailbox telling you're gonna oh, because if you try to send in some appeal months or uh in advance, they're gonna they don't know what to do with it, they're gonna throw it away. So you once you receive the letter, and even if it's a little bit later than you expect it to show up, is when you can take action. And so the easiest way to that we I would recommend doing it is uh contact your broker to help you. I mean, when you have questions about stuff. It's uh their job is to not just sign you up on a plan. Yeah, we help people. Exactly. To help you manage the stuff, answer questions you have, get it turned in properly, and most importantly, filling out the form properly. Um because when a lot of people I've had who who overthink it or try to put in too much information and it ends up getting kicked back. And they go, Well, they rejected my IRMA. You know, you said I'd get appeal. I said, Well, there's a good chance it's gonna get appealed. That's it. That's literally what it is. It's not a guarantee, it is an appeal. But it is mostly successful. And as long as it's filled out properly and correctly, and you fill on in in there's there's very clear instructions on what to do with that and getting it filled out and take it to your local Social Security office, is what I normally recommend doing because get they're submitting them online. Um can they submit ARMAS online?
SPEAKER_01I can't remember if they're well, and the new system is supposed to allow that. I still would uh try to drop it off or fax or mail it in to a local officer for sure. But the new SSA system is supposed to allow that. Um again, people can always try that. I probably wouldn't at this point in time. I think the new system is gonna be great, but it is early.
SPEAKER_00Yeah, and there's and there's and just as everything else, when you're submitting things to Social Security, there's no harm in redundancy. If you send it online, you can send it in person, you can fax and mail it to. And if it's already been done, they're gonna toss it. If it's not been done yet, or you got it in the hands of somebody who was a real stickler and looking at the rules and they weren't sure they wanted to go through, it may end up in the hands of somebody else who looks at it and goes, This is all in order, it looks good to me. Right. So it it really is which is what a lot of people don't like. They people like a lot of set rules and like when this is done, this is supposed to be done this way. Which is it's just great if you're doing things the right way. But when you're talking about Social Security and Medicare too, a lot of times you're gonna deal with people who either don't really know what they're doing or haven't been trained a lot and what they think. Like people think, well, I called Social Security and they told me this. Like, well, unfortunately the training isn't the same as everything. This is why do you go to a doctor for second opinion? Not all doctors know everything. So it's the same thing in the social security office. They're not all trained the same, they're not all the same level. So when you do have somebody who maybe rejects your appeal, it may not be because your appeal was wrong, because it would end up in their hands of the wrong person. And so this is why a lot of times I do recommend if you are having a lot of trouble at your Social Security office with Medicare or or the appeals for Irma, um, it maybe it doesn't hurt to reach out to a different office. Because sometimes you will get better results if you go to somebody else.
SPEAKER_01And I think the really one of the important things you said there was to make sure that uh you you you don't appeal uh uh until you get the letter. Right. Uh people are anxious, they want to plan, but if you do that, they will not process that. It has to show up in the system uh when that appeal shows up, that reconsideration that indeed you have one, even if you know you're gonna have one, unless the local office knows that. Uh so don't try to appeal until you get the letter. Now the letter will say uh they want you to appeal within 10 days because they would like to get that process before it's going to actually show up under some kind of a bill. But if you did not, you procrastinated that or whatever, it's all right to appeal. I think they'll actually uh uh backdate about six months, if I'm not mistaken. I think I've seen that, where retroactive six months are even further.
SPEAKER_00Yeah, even further. Okay, good. And and uh they're not the U.S. government, of course, is not great on refunds, but they are very good at credits. And a lot of times they will credit you going all the way back, sometimes all the way back to January. Now I tell people when it's if it's September and they were had no idea they could appeal and they're just now looking into it, um get it done as soon as you can. Yeah. Don't put it off because going back years behind and asking for your money back, they're never going to give it to you. But if you can go ahead and get it in now, worst case scenario, in many cases, they'll stop it now. Will they credit you going all the way back to January? Absolutely no guarantees on that. But I have seen it. I've seen it done. I mean, they can they can move mountains in those offices if they feel like doing it. Depends on who you get sometimes.
SPEAKER_01Aaron Powell All right, sounds good. Well, uh that's the IRMA. Let's let's also talk about uh the most common uh reasons that people can appeal in IRMA. Uh for those of you that this is going to be an issue, the form you want to look at, and you can easily find this online, is called an SS-44. SS-44. Now, a couple things about that form. Uh number one, it's an eight-page form. You do not have to submit all eight pages. You only have to submit three of the eight. Uh uh. Pages four through eight are actually all the instructions. Uh so the first three pages of what you would submit. Uh but there are eight different reasons uh for submitting. Uh let me just go through them real quickly. Uh could be death, could be divorce, could be marriage, work stoppage or re or work reduction. Um and so those are your common five: death, divorce, marriage, work stoppage, work reduction. Now there's three others uh that if someone goes on there, they can be a little bit confusing. Uh so let's talk a little bit about those. The first one would be it says loss of income producing property. Uh loss of income-producing property. So some people look at it and think, well, that means I owned a uh you know, some kind of rental property, I sold it and took a loss. Doesn't mean that. Uh it means that you no longer have that. Uh it uh burned up in a fire, it was destroyed in a flood, it uh uh it was in California and went down a mudslide. So in other words, you had it two years earlier, but you don't now. And so the way to prove that, of course, would be insurance um uh documentation saying that you no longer had that property. Uh I've never helped someone with that one. Uh there's also one that's called loss of uh of um a pension income or an employment settlement agreement. I've never helped anyone with those yet, uh yet, you know, my career. All the others uh I I've helped with, but but those three never. But the point is you have to have a life-changing event that's on the list of the eight. I've had scores of people say, well, I did a Roth conversion or I had a stock option buyout when I when I retired. That's not on the list at all. Uh and so it has to be one of the eight. And remember that that when you do appeal, it can't be, well, I'm I'm going to retire in July. No. Uh you have to appeal after the life-changing event. So that's the two things people have to realize. You have to uh number one, uh uh the the d don't appeal until you receive the uh the letter that you're gonna have an IRMA. Number two, it has to be after that life-changing event. Okay, so let's go through that just a little bit. So uh uh someone starting Medicare in 2026, they look at 2024. Right. So what what do they do from there?
SPEAKER_00Yeah. So you're saying let's say you're uh starting Medicare January 1st this year, 26, and you applied back in September to get started, or you were taking Social Security and you were automatically enrolled in Medicare, so you didn't have to go online and do it. Usually that letter is comes around late December, mid-late December of the year, you know, a couple a few weeks before, month before at the most, usually is when you get that letter uh from the US government saying, Hey, looked back on your taxes, you made X, Y, Z, you're gonna pay this much money. As soon as you get that letter is when you can start that appeal process. Now, as we said before, too, sometimes that letter shows up a little bit later than you expected. Maybe you'll get the a huge bill for all your first three months of Medicare, including all the Irmas and everything, and you go, holy cow, I did not expect this much money to be coming in that I have to pay for. And so what what do I do? Is a big question do I pay all that now? I mean, do I have to pay all this right now? I put in the appeal, I just turned it in. I mean, what do I do? Well, as we said, they're good at credits. So if you it they give you time, and if if you go ahead and pay and you go on to Medicare.gov and you can pay one month at a time if necessary on some of that stuff, they can break up how your payments go. But if you if you overpay, they will in many cases be very prompt about crediting you and for move for future payments. So don't worry about it. Just as long as you get your stuff turned in as soon as you get it and you keep moving forward with how you're supposed to be doing your appeals, you shouldn't have a problem with that kind of stuff.
SPEAKER_01All right. That sounds good. Well, and we want you all to know that uh when you're appealing, basically what you're saying is that uh you're saying you looked at 2024, but I had a life-changing event in 25 or 26. Right. Uh that allows me to appeal it. So what you're doing in the appeal process is you're saying, don't look two years back. I had a life-changing event that affected my income. Uh, and so you give them new numbers and you can give me the one. This year you can give them 25 or you can give them 26 if indeed the life-changing event occurred during that time. And they truly are glad to drop off uh their IRMAS. Another thing about ERMAS, uh, we'll have some people that uh maybe uh continue to be high income, but maybe 2024 they were really high income, you know, had a a very high IRMA, and and maybe their income does not go below the threshold, but maybe we moved down a level or two. Right. And folks, it is well worth your time to appeal an IRMA if you can just reduce it one level, two levels. Okay? All right.
SPEAKER_00So what would you say to somebody who says uh my income is going down to either all the way down or to a lower bracket? And it's oh boy, it's gonna be close. It's one of those lines, real close. Is it even worth it? Would you say to that person?
SPEAKER_01I would say I would for sure. Uh if it's going to um uh possibly be below it, I would go and appeal because they're gonna go back and check anyways. And if you're wrong in your number, then they're gonna bill you for that additional amount. So I would definitely go ahead uh and and take the time to do that. Exactly.
SPEAKER_00That's exactly what I say. So you know it's it's always better to appeal and be wrong than not appeal and look back and say, hey, you know what? I didn't make that much money. Can I have my money back? They're never gonna give it to you.
SPEAKER_01Well, I've had people that that really pushed it uh who knew they weren't going to um uh be below those thresholds, but they went ahead and put the numbers in and ran the risk. That is crazy.
SPEAKER_00That is crazy.
SPEAKER_01I would never ever do that. You definitely want to be honest because trust me, they're gonna go back. Now, it may take them a year before they do the audit or two years, but you you will be caught on that. So you definitely go to jail for doing that or anything like that.
SPEAKER_00I mean, that's I've had some people freaking out about that. Like, what well, what if I'm wrong? I mean, uh uh, what kind of penalty? I'm like, no, no, no, no, no. It's nothing like that. But they will get their money. They're good at getting their money. But like I said, if it's uh if it's close, I always recommend the appeal because you never know. I mean, you may end up being a little bit less than you thought. Yeah. And there's no there's no problem if it's close and you and you're you're not being dishonest. This is all a guessing game. Yeah, yeah. They want to know your best educated guess, and they're relying on you to tell them that. And it's like I said, they they don't want to take more than they have to, but they do want to take what they're owed.
SPEAKER_01Yeah, exactly right. So that's really, really good. Okay, well, I just want to make just one more statement to those of you that are married that file a separate return. Uh you will get into ERMAS very, very quickly. And I'm not telling you how to file your taxes, but I'm saying I definitely as you approach Medicare age, it'd be a good idea to make sure that you're still uh uh happy uh with the decision of uh file married with the separate return because you hit ERMAS quite quickly, uh very rapidly, and you know, uh they're they're very high. Anyway, so um I hope that helps. Uh love talking about this uh issue. I think right now about what 15 percent, maybe 20 percent of all people have ERMIS. Uh that that's gonna continue to grow for sure. And those of you that work with us uh as your broker, we will help you uh fill out that paperwork. Of course, you have to submit it, but we're delighted to make sure that that paperwork is done correctly. All right, sounds good. Well, appreciate the the comments on that. And uh if it uh this ever becomes an issue for you, if we can help you, we'd be delighted to do so. So I hope that was uh very helpful uh, you know, with the IRMA discussion. And so we're gonna uh take some questions. Uh I just want to make sure everyone knows the number. We'd love to hear from you today. It is 833-824-2004. 833-824-2004. Give us a call about anything, Medicare, Social Security, or investments. We'd love to hear from you today. Now, we also have a Facebook group that uh I think right now 60,000 people or so that are in there. And if you have never joined our Facebook group, we'd encourage you to do so. A great place to dialogue with others that are on Facebook. Our staff is in there on a regular basis uh to keep uh the questions answered uh, you know, accurately. Sometimes people will chime in and they don't always have um uh the right opinion. And so our staff kind of monitors everything. But uh you can be part of that. It's uh very helpful. Love to hear from people. And so if you're not a part of that group, uh please join that. And then we're gonna actually take a couple of questions from there. I think that could be helpful and less we'll discuss these. But uh this comes from a lady of the name of Robin in our Facebook group. It says, is there a document that I can take with me to my dermatology appointment that will help explain to the receptionist how my plan G, which she has a Signa Health Spring, will be accepted as a supplemental plan. She kept telling me that provider uh was not in their network. Okay. Also, for what it's worth, I made it known that I had two skin change spots uh that I want evaluated medically necessary. Okay, so you get this all the time. Yeah. All right, so let's just clarify just real quickly again. So she's saying, is there a document she can take uh to the dermatologist saying, hey, I'm on a supplemental plan? Why? Because the receptionist thinks uh I am not in network. You explain that, sir.
SPEAKER_00Absolutely. Yeah. And so I mean I worked uh I worked in optical for 15 years, too, so I helped people when it came to understanding their insurance and vision insurance and things like that. And that was easy for me. But then when somebody would come in with medical questions for particularly on Medicare, uh they didn't give us any training on how that worked. I didn't understand what a supplement or what an advantage plan was. I didn't understand how this was supposed to be billed. They were not very clear with that. Right. So I'd say, uh, I think it says on here you have a copay, and and we'll we'll we're just gonna build this through and you you'll you'll get a bill. That is not uncommon when it comes to how providers are trained and how this And this is a very much a provider issue, not a supplement or a Medicare issue. Everybody's a little bit different on how their training comes in. And so we're all trained to think our whole lives when it comes to insurance that this is network-based insurance. We've got to make sure are it in network? Is it accepted? Where can I take this? Where can I not take this? And so when we're dealing with Medicare and we throw all that out the window on a supplemental plan, there's no more networks, there's no more HMOs or PPOs or referrals or pre-authorizations or any of that stuff. We understand now, well, I can go in anybody I want as long as they take Medicare, they're gonna accept my plan. But the provider themselves, they're gonna see this as this is XYZ insurance. We don't take that one. So, you know, we're not gonna accept this. Like, no, no, no. I I don't have to educate you on how this stuff works. I shouldn't have to educate you on how this stuff works. But in the end, you know what? It's okay. Well, all you have to do is take my cards, my Medicare card, my supplemental card. Here's my first, here's my secondary. Go ahead and build them, and you're just gonna send me whatever's left. You don't have to take in additional documentation beyond that. And if for whatever reason, and I've had this happen before, where a provider said, we're not gonna bill your secondary, fine. What I tell people in that case as a broker, send me the bill. I'll send it to your coverage, and this is gonna get covered no matter what. They have to pay where A and B pay first. So don't worry if your provider decides to be non-compliant with your insurance, it's gonna get paid no matter what. There's always it's it's it's set in the system. The government, federal government says they have to pay where A and B pay first. So don't worry about them not accepting it, and you're gonna get this huge bill. It will get paid no matter what. Right.
SPEAKER_01Yeah, so this is a training problem.
SPEAKER_00Yes.
SPEAKER_01Yeah. So this is uh uh a receptionist that uh doesn't understand the difference between supplemental plans and advantage plans. Advantage plans uh do not have to be taken by providers. Original Medicare uh and supplemental plans, they have to. So this truly is just a training issue. Um and so as Evan said, no documentation, given the cards. Um and it it can be frustrating because sometimes people will call in advance uh to see if their plan is taken. So I tell people all the time, listen, if you're on a supplemental plan, you do not have to call the provider and ask them if they take your plan. If they take original Medicare A and B, they will take the supplemental plan. So don't even ask you because you could get an untrained receptionist that has no idea.
SPEAKER_00And don't start saying carrier names either. When you're I mean, just say I got a plan G. I have a you take Medicare, great. You take my plan, I'll see you then.
SPEAKER_01Yeah, exactly. 99% of all doctors take Medicare, they're gonna take your supplemental plan. I would add, though, um uh we we have seen uh where there are times when a doctor only takes advantage plans, and that's all they'll take. You know why? Because the advantage plan owns them. Now it's very rare, but it can happen. Uh so if you're going to a doctor that only takes advantage plans because they're owned by the advantage company, uh then you need to find an you need to find a new provider. And again, it didn't happen often, but it does happen occasionally. Uh but 99% of all doctors take original Medicare. So go where you want to go, and you may have to be the one that trained the receptionist that they have to take your plant. Right. So uh great question. All righty, let's keep going. We got another one from the Facebook group. And uh this person says, I have had sleep apnea uh for 16 years. My recent sleep study indicated no longer suffering um uh from this due to a a recent large weight loss. Doctor ordered another sleep study, as the prior one did show some uh OSA, it must be the the acronym for sleep apnea, uh, when sleeping on my back. My question is will Medicare cover a second sleep study within a six-month period? The typical cost for a sleep study before all the Medicare and other discounts is almost 8,000. So I'm concerned. Thanks for any insight into this uh concern. Any insight into that question?
SPEAKER_00Yeah, and it's gonna be the same with uh anything else that you're doing in Medicare. Everything you everything you do has to be medically necessary and has to be ordered by the doctor. So and there could be a lot of situations where Medicare wouldn't cover a second or a third treatment of this or that that you're trying to do. But if the doctor orders it as medically necessary and they're coding it to Medicare as something that they ordered and they think is necessary, you can get coverage for those kind of things. But there's a there's a general rule on how things generally go, and so you can follow those, but this is very much, once again, this is gonna fall back on the provider. How is your provider gonna be billing this specifically? Right. And as long as they are billing as necessary, you're in the clear.
SPEAKER_01I would say this. I think and I think you're exactly right, Evan. Uh I think that second opinions are not uncommon. Medicare will cover them. However, I agree with you. Uh if I were you and she doesn't give us her name or he or she, but uh you want to make sure that the provider does their due diligence to make sure they're gonna get paid. Okay. And so uh they can check into that. They can find out if indeed is there a code for a second opinion on a sleep study. Um and so I I've never had this particular client ever ask me this question before, but uh the provider, I'd put it back on them. They want to get paid. Right. Uh and so they have a relationship with the um uh Medicare offices so they can find out if it's covered or not.
SPEAKER_00It's a very safe blanket for everything in Medicare. Just make sure the provider is getting paid and make sure that they know what they're doing and how they're billing it. Because if you just go stuff if you go on and you just start requesting stuff, you're gonna start you're requesting bills at that point. Exactly.
SPEAKER_01That's good. Great question, though. I've just never experienced it. All right. So someone else in our Facebook group says I have Medicare with a seminal plan G. I have a knee replacement in Febne replacement in February, and I'm scheduled to have the other one done next week. But when my primary care physician entered pre-authorization blood test, he said Medicare is refusing to pay for two of them. The combine costs is five hundred dollars. Does this sound correct? Any opinion on that one?
SPEAKER_00This is for the blood test, is what they're saying. Not the knee replacement, but the blood test. Yeah.
SPEAKER_01Um entered a pre-authorization blood test. Um he said Medicare is refusing to pay for two of them.
SPEAKER_00Um I would say I I I don't it's not a broken record here. This is coming down to the uh the coding done by the provider. So they put it in as something that may be a uh pre-65 code or something that they're used to doing when it comes to blood tests and blood work, as something that may not necessarily be coded as necessary. This is kind of a preemptive or a double check type of test kind of thing, in which case Medicare is gonna look at that and they're gonna reject non-medically necessary things. And so that could could be very well what happened in this particular situation.
SPEAKER_01Yeah, exactly right. Yeah. Yeah. I think if you have any doubt about that, uh you may want to call Medicare yourself. Um and uh if you call them, you could tell them the situation and they may be able to give you something a little bit more direct. But I'm with Evan, I'd put it back on the provider. Say, hey, if this is something medically necessary, it should be covered. So are you sure um that your prioritization team actually did did proper coding on it? That would be my opinion. So uh yeah, some more homework should have to be done here on that one.
SPEAKER_00Yeah, for sure. Absolutely.
SPEAKER_01All righty, we have another one here. It says, uh has anyone had cancer in the group while on Medicare? Curious if it is better to have private insurance or if Medicare with a gap plan would be better.
SPEAKER_00Oh, yeah. I uh 38 years old. Uh next next week uh month, uh we're actually 39. Um if I could have Medicare today and a supplemental plan, I absolutely would. Even if it cost me twice what it cost people in many other states. Um being seeing how well it covers and what it's designed to do and how well it's accepted and how well providers.
SPEAKER_01Yeah, well, define what you mean by that, though, when it comes to Medicare. Because Yeah, supplemental supplemental plan.
SPEAKER_00Supplemental plan G. If I could have a G today, I would. But they don't let us have a tour 65. I got 30 years to go before I can get on Medicare. I hope the system looks even remotely close to like it looks like today. The way that it is set up and the abilities you have to see the doctors and hospitals that accept it, the way that they get paid very happily by the federal government, which allows them the freedom and access to do what they want without being interfered with by an insurance company is uh from what I have seen, second to none.
SPEAKER_01Yeah, I I would agree with you too. I mean, I I think if someone does have an advantage plan, they certainly have coverage. But there could be some issues. Uh there could be some network issues. They may not be able to go to the oncologist they want to, or even the hospital they want to if it's not gonna be in the network. It doesn't mean to say they won't get taken care of. Uh but the advantage plans are gonna give some limitations. It's just the way they work. So I agree with you. I think if I had uh the the choice between a private health insurance plan, which which could still be great insurance, but normally you're gonna have a deductible, you're gonna have max out-of-pocket that's pretty sizable. With Medicare, if I had that plan G, I have a B deductible 283, I pay my premium, I'm done. Um as long as they take Medicare, I can go anywhere I want, which 100% of all hospitals do, 99% of doctors do. But advantage would be totally different. Uh covered for sure, but pre-authorizations, network issues, all those kind of things could come in.
SPEAKER_00And that's super elite hospitals, more and more of those. So this is what I tell people about places like like the Mayo Clinic, you know, like they they work very hard to make sure that you're getting cutting-edge medicine. Right. And and some of that stuff's not cheap to get to get the kind of medicine and treatment that you want. But according to an insurance from an insurance company's perspective, if they have a chance to say what your treatment is, and they say, well, shoot, they want to do a $350,000 treatment, but this has been proven to be successful most of the time with the radiation pill. It's only $20,000. We're gonna cover the radiation pill. And so that happens so often that eventually these elite hospitals that are trying to push through the edges and the boundaries of medicine say, We're not gonna have to deal with these roadblocks anymore. Yeah, absolutely not. So no more advantage. You know, what we'll go with Medicare has a blindfold on and says, if you think it's necessary, we're gonna pay you for it, and they'll write the checks, and they're good with that. And that's the kind of treatment I want. I want completely between me and my doctor, and no one else in between. Yep.
SPEAKER_01Very good. All right, that sounds good. Just one more here. Teresa says this. I just learned that the hospital in our area has dropped United Healthcare insurance due to a disputes that cannot be worked out. So now I have to pay out-of-network cost. Can I change my supplemental insurance for uh this reason? Okay?
SPEAKER_00I think a little confusing on the terminology there. Yeah. You said supplement. Uh obviously a supplement wouldn't matter because there's no networks unless you're, once again, the receptionist is a situation where they don't know. But I think what you mean to say is an advantage plan. More than likely, I'm assuming, if you're talking about networks, that's what you're referring to. Um so yeah, this is where it can get a little bit tricky. Um, changing advantage plans mid-year. Aaron Ross Powell, Jr.
SPEAKER_01Yeah, let's let's pause for just a second though. Okay, let's uh because I'm I'm seeing this question differently, okay? So I just learned that the hospital area is dropping out of health care insurance. So that hospital dropped you on health care advantage plants. Correct. Okay. It doesn't mean that they dropped uh everything you know in health care. Trevor Burrus, Right. Certainly not supplemental plants. So pick up from there, because that's the way I interpret the question. Keep going. Right. Okay.
SPEAKER_00And I interpret it the same way. Her wordage of supplement at the end of that was kind of the thing that threw me.
SPEAKER_01No, I think she's probably on a supplemental plant.
SPEAKER_00Oh, that's what I'm saying.
SPEAKER_01Can I change my supplemental insurance for this reason? Trevor Burrus, Jr.
SPEAKER_00Gotcha, gotcha. Do not you don't have to change. You're accepted exactly the same as you did before. When they say we're not taking XYZ insurances anymore, that's literally just we are out of the networks of the advantage. We're not we're not taking that. Original Medicare is still there, your supplement is still there, that's not changing anytime soon. You're still accepted just like before, no difference.
SPEAKER_01That's right. They will not drop your United Healthcare supplemental plan. Right. They have every right to drop the advantage plan if they choose to. We had this happen last year with Aetna. Uh there were several hospitals that just Aetna was no longer a network. Uh and so we had people call, well, they won't take my Aetna supplemental plan. Oh, yes, they will. Right. They really, really will. So again, it's not across the board United Healthcare, it would be just the advantage plan only. Right. Okay. So that's the way that works. Yep. All right. Sounds good. Go back though. You were making a comment, though.
SPEAKER_00Let's say she is on advantage plan. Let's say she is on advantage. She just misused a word there. And meant to say advantage rather than supplemental. And so it's like, well, what do I do in that situation? And that is a common problem. Right. You know, doctors and and and hospitals um switch networks mid-year. And so uh it would be really great if there was a golden code. This is what I this is what I would love if I was in Congress and make a change. I would add a code. I would add one golden change per year for whatever reason, like doctors change to networks. Uh-huh. And you could you can make that change. But there is no golden code for that. Not yet. You're right. Not yet. Hopefully, they're hopefully soon. Whoever is listening in the powers that be, please put a code in there. That would make everyone's. Just so you know, they tried. They did.
SPEAKER_01I've got an article right here in my in my my notes. Listen to this. Help for Medicare Advantaged Patients who lose doctors is shelved for now. Yeah. They just tried to do this. They tried to put in uh uh a code for people mid-year in case this happened, and it didn't it did not make it through. So well, you know why insurance companies fought that like crazy. They don't want that, they don't want they don't lose that client.
SPEAKER_00Yeah. Um Or I mean gain that client. I mean it can go both ways, obviously, but some of them aren't looking to gain people right now. They're looking to uh shore up what they have, if not maybe cut down in some areas. So I can see where that goes.
SPEAKER_01Yeah, but once they had that client on the books, they're not interested in them being able to get off of that. Getting that payment on a monthly basis. So I know it could it could go either way. But I think the big thing is insurance companies fought this because they don't want another SCP code.
SPEAKER_00Um they they want to keep it.
SPEAKER_01Yeah. So let's talk about this situation. So if someone does have this happen, uh if they're if they're in the midst of treatment, there will be a continuance of coverage. Uh but if you're not in the midst of treatment, then you're gonna have to go find a new hospital.
SPEAKER_00Right. Or at least until AEP at the end of the year when you get a chance to switch to somebody else who is in the network. Um once again, gonna have to be watching that is because they could announce we're gonna be in network with this new carrier, and before the end of the negotiations end, it's uh March or April of the next year and fell through. Didn't work out. And what so there there are a few election codes throughout the year. You got the AEP, you got the OEP in the first quarter of the year. Um they to just in case something like that occurs, you can make one change, you know, to kind of help you out. But tell them the dates on that. I think that's important to be able to do that. So January 1st through March 31st is OEP. That's if you've after you've made your selection during annual enrollment, October 15th through December 7th, and something changes and something isn't quite what you thought was, or your hospital announced it's not going to be what you thought it was gonna be for networks, you have that opportunity, those those two sections. That's that's I mean, realistically almost half the year. So you got the last quarter and the first quarter realistically to make changes. Um, if something happens in the middle of the year, sometimes there are election codes to make changes. You can't change every month, um, but some things might come up. They're not a guaranteed switch for this or that, depending on your circumstance. Ask your broker, of course, and see, hey, is there any way I can try to make this change if necessary? And this is really only going to be in that one of those situations where I've got to see my doctors in hospitals. I refuse to change, or I'm in an area where there's one hospital. The next one is a hundred miles away. I have and I only have this plan they don't take, and I'm in an HMO. What do I do? And so this is where you you really try to find there's there's no guarantees that you can make that change.
SPEAKER_01And this is one of the beauties of supplemental plans that uh everyone needs to realize uh you don't you will not deal with this kind of thing uh with the supplemental plan.
SPEAKER_02Right.
SPEAKER_01Uh 100% of hospitals take original Medicare, they'll take your supplemental plan, and they're continuing to do so.
SPEAKER_02Right.
SPEAKER_01That's just the way it works. And again, not bashing advantage plans because there's a place for them. Uh but when people pay a premium, this is why they do so, because they don't want to lose their coverage. They don't want to have to worry about year to year is my doctor in the network any longer. Okay, so eliminate those frustrations.
SPEAKER_00Not supplement versus supplement, but supplement versus advantage, it's a kind of a get what you pay for. You mean if you if you put something into it, you will get something out more than just the uh the the the pri the unknown price that you can get for a zero dollar premium.
SPEAKER_01You know, I've been doing this now, well, insurance, 17 years, 15 years in Medicare. And I've had lots of doctors, nurses, coders, all kinds of people in the medical field. And and honestly, I've never had one that I'm aware of ever go on an advantage plan. Not one time in my whole career. Okay. And so I'm not saying it doesn't happen, uh, but it's never happened to me. Right. And the reason for that is because uh the people in the medical field see what happens when people need um uh you know to go through a preauthorization, it gets denied or it gets delayed, and they're saying, I don't want that to happen to me. Right. It's kind of like a mechanic that uh knows usually when the transmission is gonna go out in a car or uh when there's gonna be problems in the car because they're under the hood every day. They see the problems with mechanics. They say it all the time. That's right. So that's the way it is in the medical field when it comes to insurance. They see what happens uh with people on advantage plans. Had a gentleman recently uh on a vantage plan, uh, went to a skilled nursing facility 13 days, and then they said, we're done paying for his his skilled nursing bill, send him home. And so again, that wouldn't happen original Medicare.
SPEAKER_02Right.
SPEAKER_01I average day, you know, 45 days right now. So those kind of things happen. So I say all that because people need to be mindful that when you pay a premium for a submodal plan, uh you are getting something out of it.
SPEAKER_02Right.
SPEAKER_01You are. Um almost unlimited providers, no pre-authorizations, um, permanent plans, portable plans, you know. So there's a lot of benefit to that. All right.
SPEAKER_00So an awareness of our own uh of our own mortality when it comes down to it too. We're all getting older and things aren't gonna be like they were. I mean, people say I've I've been healthy my whole life, never been to the hospital. Great. I hope it stays that way. Exactly. I really hope it does. Um statistically, not as likely, but you know, this is where you gotta you have to plan ahead.
SPEAKER_01Right. Yeah. I had a guy recently that wrote me, and uh, I did not deal with him, one of our agents did, but he he wrote me and said, Marvin, um uh we went with the supplemental plan, uh though both he and his wife were healthy, and he said within one year he was diagnosed with prostate cancer and his wife had a heart attack. And uh they went with supplemental plans. You said we're very glad that they did. They looked in the mirror that day when they made a decision. I can't just be thinking about my health today. Right. Because it could change, and it did change for them, you know, very drastically.
SPEAKER_00Yeah, many stories like that myself. Exactly, right. Absolutely.
SPEAKER_01Yeah.
SPEAKER_00Yeah.
SPEAKER_01And we got two other great questions here. Let's um let's get to these and then uh we'll be uh leading for today. But I thought this were really good. Someone uh who turns 65. Here's the question. Someone who turns 65 in January and is uninsurable decides to go with his former employer's retiree group Medicare Advantage plan. He decides at a later date to switch to a Medicare supplemental plan. Would that be a guaranteed issue, or does he have to drop the group Medicare Advantage Plan within six months of getting Medicare Part B and use open enrollment? Thank you. Okay, got it? That's loaded. So someone turns 65, uninsurable, decides to go to this former employees retiree group Medicare Advantage plan. Yep. Okay, got it.
SPEAKER_00Good. Yeah, so yeah, first of all, it it's the second part of that where you have to do it within the first six months. Because um if you you said guaranteed issue is only gonna be if they're taking it away from you, and it's through no fault of your own. Involuntarily. Involuntarily. You can't just end the policy and say, hey, I I lost my plan. Because they're they have to have proof that they ended it, they they terminated, you you moved out of the area, something, something where you're losing it through no fault of your own. Um so um you can't set your watch by those things. We don't know when those things are gonna happen. So you you'd be rolling the dice when that opportunity may come to you in the future. So you would have to do it in that first six months. Obviously, if you're a super healthy person and you never go to the doctor and never take meds, you can once again roll the dice and maybe change later on down the road through underwriting. But there as far as guaranteed acceptance, you want to make sure it's in that first six months.
SPEAKER_01Exactly right. So very good. So just know, folks, once you've started that Medicare B, you have that six-month window, which includes your birth month. So if my birthday is in January, I've got all the way through the end of June six-month window, no underwriting. So you'd want to make that switch then for sure. Right. Yeah. If it was involuntary, uh meaning that the plan dropped you, then it would be different. You would have a uh uh uh extended guaranteed issue period. Right. Uh but don't roll the dice in something like that. I agree with you totally. Okay, just one more. Uh this lady says my husband is going to be prescribed a new med in a few weeks. It is not on his formulary. What can I or the doctor do to see if they will cover it?
SPEAKER_00Gotcha. Yeah, definitely ask your doctor and talk to about that. They may um there may be alternatives to that medication. If it's not in the formularies of Medicare, there's going to be potentially step therapy where they may want to do uh a lower cost or a different type or something else. If there is no alternative and the doctor says, nope, this is it, and uh, and oh, I know your tolerances. Uh we can't take uh this generic or that, we've tried it, or it's uh not you're something you may be allergic to, or there's just I will not prescribe anything other than this particular medication. Um then it's when you're gonna start working through the uh the prior authorizations and and trying and the and the um formulary exceptions um to try to get the insurance companies to pay that. Will you know ahead of time that that is going to be covered? Uh no. There's just there's really no way of guaranteeing that insurance company is gonna cover a specific medication. Good chance if the doctors are on board that they're not going to provide anything alternative and this is a a medically necessary medication that you need, that you will get what you need out of it, but it's no guarantees that they have to do that.
SPEAKER_01But I think as a general rule, we could say that normally normally you're gonna get a formulary exception. And I would just be proactive if it were me. Get on it. You say here in a couple weeks, have the doctor write the prescription. Uh and if it uh is denied, now you've got some time, you can go through that formulary exception process. Okay. So that's what I would do. So uh because I think as a general rule that the Part D plans uh do everything they can to make sure people are getting the proper medication. Uh but it is true. If there's equivalence, uh alternatives uh that are cheaper generics, you're gonna have to try those. Right. But if not, I think you'll get it approved. Right.
SPEAKER_00Okay, and if if doctors are not real hard line with the insurance company, too, to say, yeah, well no. No, we haven't tried this other thing, but I'm I prefer they stay on this one. It might not be enough.
SPEAKER_01And if you do get denied on something like that, then always appeal. Yeah. I think what what seventy percent of all appeals go through. I think they ought to approve the first time, but sometimes people do have to appeal. So uh you'll probably be successful in getting that medication, more than likely. More than likely. Yeah. All right. All right. Great question, though. Yep. All right. So that's gonna be it for today, Evan. Enjoyed as always being with you. Absolutely. Appreciate all your hard work uh as you serve people around the country. Uh now tomorrow's uh broadcast, we're gonna be talking about specifically about cancer. Uh we're gonna uh look at the issues uh of that cancer coverage, whether you're on a Med Sub plan or a Medicare Advantage plan. We'll get into the details about those two types of coverage if indeed someone got that cancer diagnosis. Now, if you need any help, folks, uh let me just give you our number. You can call in to get help uh with an agent such as Evan. Uh you can call 800-782-6676. That's 800-782-6676. So if you need me to help, our office is open Monday to Thursday, uh, 7 to 7, 7 a.m. to 7 p.m. Then on Friday, 7 to 6. So we'd be delighted to serve as your broker. And as always, there's no cost when you use a broker, and we'd be delighted to serve you in any way. Take care.