r/medicare

Last October 2025 I went on Medicare and obtained my medigap Part N through Cigna. A few months later my medigap transferred to HealthSpring.

Since meeting my deductible, I’ve had several Physical therapy sessions and 4-5 doctor office visits. No one has collected a co pay up front, nor have I been billed for my copay which should be up to $20 under Plan N.

Medicare EOBs show I “may” owe the remaining 20%. My HealthSpring patient portal show that no claims have been submitted.

Medicare is showing my other insurance to be LOYAL AMERICAN LIFE INSURANCE CO which I believe is the underwriter for HealthSpring

Why might I not be incurring a copay? Or does billing by the provider just take several months?

I'm trying to decide between Healthsprings Plan N ($111) and Bankers Fidelity Plan N ($93). BF, in my state on N, has very low enrollment, about 700, but their loss risk is low, about 50%. Healthsprings has much higher enrollment on N, about 70,000, but their loss risk is about 98%. BF also has lower increases (though they are supposed to increase August and haven't yet). BF has only been in the state for three years, at least with this pool. No one seems to be able to tell me which is actually true. So this might be risky. I am concerned since I'm picking plan N on a company pulling out of the state and having to go through underwriting. I need to make a decision within the next few weeks.

So I’m currently on Medicaid (WI) because of low income. If my income remains low (under the FPL) can it cover things like premiums and copays when I’m in Medicare? My mom pays like $6-7k per year for her medigap coverage. I don’t have that kind of money, even with SS. I have about 5 years to do research and figure this out, but any help would be appreciated.

I signed up for Medicare part B in October thinking I would retire at the end of the year. As it happened I still have not retired and I am covered by my employer'group plan which includes drug coverage .

I picked up a Medigap policy in December knowing that I had to get this policy within a few months of getting Part B

When I signed up for Part B I sent Medicare a statement of continuous coverage which Medicare accepted.

I also signed up for a Part D plan through Humana which went into effect in January. I missed and just found a letter from Humana stating that I did not have continuous coverage for Drugs since 2016 and that I needed to send them a letter showing coverage by January 9, 2026. I literally just found this in a pile of paperwork in my kitchen. Yes shame on me for missing the letter.

I don't think that Humana is charging me a premium at this moment. Can I submit the statement of coverage at this late date to avoid the penalty?

Doesn't the statement I submitted in October cover the Part B letter?..

Any advice is appreciated.

Thanks

Currently, I have a diagnosis of Sleep Apnea of greater than 20%. I have a recent clinical study showing my Sleep Apnea is controlled with a Rx CPAP to less than 5%.

My BMI is around 34%.

It is my understanding that to qualify for Medicare Part D, one must have a BMI of 30 or greater AND sleep apnea not controlled by CPAP therapy.

Do the above conditions allow the medical provider to check the NO box on the Bridge Rx request concerning whether the patient qualifies for Part D coverage?

I do have the auxiliary qualifiers for The Bridge criteria. A1C of 6.1 and a fasting glucose of 101.

I assume all of the above conditions are to be defined in the application filled out by the medical provider on the initial bridge paperwork.

Where on the bridge application does the medical provider affirm that the sleep apnea is now controlled, thereby initiating the denial statement from Part D? Or can the medical provider check No on the Bridge application due to the Controlled Apnea?

I am in the weeds. Help me with clarity.

My primary interest is getting Zepbound Rx, with a close second of cost saving.

Repost to more communiti

Does any one know of any private federal benefit consultants who specialize in FEHB Medicare and IRMAA issues?

I hit 65 last month and officially aged into Medicare eligibility. I thought I'd done enough research ahead of time to feel prepared, but the moment I started actually comparing plans I realized I had no idea what I was doing.

Original Medicare versus Medicare Advantage, then Part D on top of that, then Medigap supplements with their own lettered categories. Every time I think I understand one piece, something else comes up that changes the picture.

My main concern right now is figuring out whether to go with Original Medicare plus a Medigap supplement or just pick a Medicare Advantage plan. I have a couple of ongoing prescriptions and I see a specialist regularly, so keeping my current doctors is a priority.

I talked to one broker who pushed hard toward Advantage, but I've seen enough posts online suggesting that Medigap gives you more flexibility long term, especially if your health needs change.

For those of you who have already gone through this decision, what factors ended up mattering most to you? Did you regret your choice after the first year, or were you glad you went the direction you did?

Not looking for personal medical or legal advice, just hoping to hear real experiences from people who have been in this same spot. Appreciate any perspective you can share.

Hi. Hubby and I both turn 64 this week and have been inundated with Medicare info for the last 3 months or so. So confusing and pretty sure I can attribute more than one headache to reading so much of it. Hubby is retired career Navy so next year we qualify for TriCare for Life. Two questions for now-

Question one...How does Tricare for Life work with Medicare? Good way? Bad way?

Question two...Hubby is still working and begins a three year out of country work contract in September. He will fully retire when he gets back in 2029. Will that affect Medicare costs for us? I am fully retired but do not plan on taking my SS until hubby fully retires.

I am trying to switch Medigap plans during California's annual "guaranteed issue" period lasting 60 days after one's birthday (due to my current Medigap insurer (UHC) raising its rates steeply since I signed up). I'm finding that insurers just don't respond. I could go through a broker, but that would exclude some of the less expensive carriers. For example, I have contacted 2 different State Farm agents (policies only sold via their agents, not brokers), and neither has responded. Similarly with another carrier that uses direct online applications. I have had a minor surgical procedure in my first years on Medicare, but am healthy (although I suspect that something that seems minor may nonetheless increase actuarial risk estimates in the insurers' models). It seems like "guaranteed issue" rules are only as good as the state's willingness to enforce them? Or maybe Medigap policies have low commission rates for agents so they don't prioritize a response?

Let’s say that one spouse is 58 and the other is 63 and they are both retired. They can control which spouse receives the household income by having only the younger spouse withdraw funds from their IRA. Is it possible for the older one to avoid IRMAA for 5 years by filing federal taxes MFS and having the younger spouse take all of the IRA withdrawals? Is this a stupid idea or brilliant?

I live in New York State the Medicare Part D plan premiums range from $35.70 to $173.60.

Do they cover the same drugs? Why is there such a wide gap in premium costs? Are the more expensive plans actually worth the additional money?

I am trying to figure out what plan d plan to get when I move my wife and myself off of companies insurance.

Thanks In Advanced

Al

Terry Savage recommended this company along with BoomerBenefits. I already know I do NOT want an Advantage Plan. I just need assistance in picking an actual Medicare plan, because I can’t find historic data, such as price increases, on the companies. Yes, I’ve talked with local STEP person, which provided general info that I already knew. BoomerBenefits reps get paid by insurance companies, which I’m not a fan of due to bias/ influence. With 65-inc, one pays a consultation fee. I’m ok with paying a consultation fee if it saves me $ in the long run. So, has anyone here used them? Thx

My wife is getting money, from her Mom's
Home sale who died recently, that is going into an estate. Will that money, profits from sale, be included as income for 2026? If so, that will cause IIRMA extra premiums to kick in which I'm trying to avoid. Also, if she takes any money out of the estate, will that be counted as income?

Hi all,

My mom recently enrolled in Wellcare Value Script prescription plan. We had input her medications and all her medications were $0 aside from one. Well, we went to go pick up one of the medications that is supposed to be $0 but CVS says it's not covered by Wellcare. The Medication is Prednisone and it's a T2 drug on Wellcares formulary list and as mentioned before, was $0 when I input her medication with the correct dosage, quantity on the Medicare tool. I'm wondering if anyone's experienced something like this and what are we supposed to tell the pharmacy, especially because now I'm concerned whether her other medications are covered even though Medicare tool said they were.

Previous update.

I tried to go through underwriting to get back in a Plan N but the insurer rejected it without explanation. All medical questions on the application were answered "no". I'll have to go with a Plan G, with the same insurer.

As someone that works in a doctors office and submits PAs, I want to clear up some confusion about the GLP-1 bridge program.

I want to start by saying I appreciate that this program will get these meds to many people that need it, but it leaves a lot of Medicare beneficiaries behind.

If you have type 2 diabetes, moderate to severe obstructive sleep apnea, or MASH you do NOT qualify to use the program. You have to get a GLP-1 medication approved for those conditions through your Part D plan. Even if the Part D copay is astronomical, you still can’t use the bridge program if you have any of those 3 diagnoses.

It doesn’t matter if the provider doesn’t even use those diagnoses and only submits the PA for obesity, you still don’t qualify. When we submit the PA, the provider has to attest that you do NOT have those conditions. If the provider selects that you DO have any of them, the system automatically denies it and kicks it back saying it has to go through Part D. You can't get around this if you have these conditions because that would be committing Medicare fraud.

I submitted multiple of these PAs today and confirmed this is exactly how it’s being processed.

You do still qualify if you have mild obstructive sleep apnea and meet the other criteria, because mild OSA isn’t covered under Part D, only moderate to severe.

This is directly from the CMS website info for prescribers and the PA form that I've linked below. I recommend looking over these because this is exactly the guideline providers are following when submitting these PAs.

https://www.cms.gov/glp-1-bridge.pdf

https://www.cms.gov/files/document/glp-1-prescribers-c-1.pdf

I hope this information is helpful.

Scenario - I’m in a state where going from an advantage plan back to original Medicare and a supplement requires underwriting.

If I would move to New York while on my advantage plan and immediately apply to switch to original Medicare and a supplement then move back to my original state (meeting any time requirement there may or may not be)and get a supplemental plan since I am now on a supplemental plan in NY?

TLDR; trying to determine if it’s Medicare or home health agency that’s the problem and if it’s worth it to try to find a different agency or we’ll get the same answers.
My mom just got home after a month in the hospital and an acute rehab. She went in to the hospital just barely able to walk for a fall and now is completely wheelchair bound and with a catheter. Coming out of the rehab, the social worker said in her experience she would qualify for somewhere around 20 hours a week, which would be really helpful for the bridge of finding long term care considering she needs assistance for every transfer, toileting, showering etc. the supervising nurse from the agency today came and told us 6 hours a week total for 2 hours MWF, we have no say on time and it can be whenever not consistent timing. He wouldn’t tell us straight if that was because that’s all Medicare covers or because of their staffing, she will also only be getting skilled nursing 2x a week for the catheter maintenance. Other big issue is they are telling us it’s a full week and half till some one can come; considering this is meant as a bridge coming out of a facility I’m alittle lost on how that’s acceptable, chances are we’ll already have an actual aide starting making this service kind of moot and also if they’re not able to give us a schedule a head of time there’s no way to plan coordination. I do understand her case is atypical for 2 reasons 1) she is currently in limbo on a diagnosis so we keep hitting a wall in a lot of places of things not being covers (they think it is probably als but she needs to get to specialists to confirm a diagnosis.) 2) besides the catheter she is mostly medically stable. I want to know if we’re getting f’ed over by this agency or it’s just Medicare itself that’s the problem. Secondary would be now that we’ve have the intake visit from this agency how much of a hassle would it be to switch if it really is the agency. We are in a major metro area and are more or less straddled between what is probably two territories so I’m thinking one that is more based out of our adjacent county could be better than this one.

Jul 02, 2026 CMS Acts to Strengthen Care Quality, Cut Drug Costs, and Slash Out-of-Pocket Expenses for Medicare Beneficiaries

from the link ~

Medicare beneficiaries deserve a program that pays for the right care, in the right setting, at the right time,” . . . “This proposed rule focuses squarely on patient affordability by strengthening our utilization management tools, aligning drug payments with actual acquisition costs, and removing site-of-care disparities that have unnecessarily driven up costs for millions of seniors. We are committed to ensuring that Medicare resources are directed toward clinically appropriate, affordable high-value care for every patient we serve.”

end copy paste -

If they can make these thing fly, it will be beneficial to the Medicare program and beneficiaries alike.

Reserving judgement to see if they can make these things fly - other administrations have tried it before only to be shot down somehow and nothing changed - maybe this time they can get it done - saving money for the Medicare program and beneficiaries alike.

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Thought someone here could easily explain. I got on SSDI last year ( I became paraplegic). I did not start on Medicare at that time. I was and am still on private insurance. I worked in healthcare and know that straight Medicare is the way to go. Can I start on Medicare at any time? Is there a sign up period, like when you have insurance through a job. My understanding is that you are automatically placed on Medicare after 2 years, but I’m hoping for sooner.
Thanks in advance.