Insurance FAQs

When one becomes eligible for Medicare and is looking for additional coverage, there are two options. Medicare Advantage Plans or Medicare Supplements, aka Medigap plans. Both plans are designed to do the same thing, which is give you better coverage than just Medicare, but they work differently. Simply put a Medicare Advantage Plan is typically a network driven plan, the most common type of Medicare Advantage plans are HMO’s and PPO’s. Medicare Advantage plans, also known as MA, are NOT similar to Medigap plans – they are different. Members get their benefits from a private insurance company. Medicare Advantage plans often have networks of doctors you must use when seeking medical care and also pay co pays for services when you use them. These plans typically have very low monthly premiums per month IN ADDITION to your Medicare premiums.

Medicare Supplements aka Medigap plans are plans that pay after Medicare approves and pays its share of your claim. They are Medicare gap insurance, helping to cover the gaps in Medicare that normally you would have to pay. This includes things like deductibles, coinsurance, and copays. You can use your Medicare Supplement plan at any provider in the nation that accepts Medicare. This makes Medicare Supplements great for travel or for people who live in more than one state throughout the year. Medicare Supplements plans do not include retail drug coverage, so you’ll want to purchase a standalone Part D drug plan for your medications. A Medicare Supplement does not cover routine, dental, vision or hearing services either. Since Medicare itself does not cover these items, your supplement cannot pay anything toward them either.

No, not all Medicare Advantage Plans are HMO’s. There are Medicare Advantage Plan PPOs, as well as Medicare Advantage PFFS (private fee for service) Plans and Medicare Advantage HMO-POS (point of service) plans.

Medicare Advantage Plan HMOs are health maintenance organizations through which Medicare beneficiaries can access their Medicare services. They are often called Medicare-managed care plans because your care is managed through a network of doctors and hospitals specific to the plan. The insurance company contracts with certain doctors and physicians in your local area to form a network. You will select a primary care physician (PCP) who will coordinate your care. If your PCP is unable to treat a health condition, he or she will issue a referral for you to see a specialist network. Some services like preventive care, mammograms, and emergency visits may not require a referral. Some plans may not require referrals for specialty care. When you enroll in a Medicare HMO, you agree to obtain your care through the plan’s network, except in emergencies

Medicare Advantage Plan PPO’s. The term Medicare PPO stands for Preferred Provider Organization. It means that the Medicare insurance company has a network of health providers that have agreed to see the plan’s members at contract negotiated rates. These network providers will coordinate your care. In a Medicare PPO, you will generally pay lower co-pays if you see providers that are in the network. You are not usually required to choose a primary care physician or get referrals to see specialists.

Medicare Advantage Plan PFFS plans. PFFS plans are unique in that you can see any doctor in the country that participates with Medicare as long as they are willing to accept the terms and conditions of your plan. A Private Fee-for-Service plan is NOT a Medicare Supplement Insurance plan. Providers who do not contract with the plan are not required to treat you except in an emergency. This puts the responsibility on your shoulders to discuss with any healthcare providers whether or not they agree to see you and bill the plan.

Medicare Advantage HMO-POS Plans. Medicare Advantage HMO-POS stands for Health Maintenance Organization Point-of-Service. It’s a type of Advantage plan (Part C) that provides coverage for in-network services. However, there may be some services that can be covered if you go out-of-network. Most hospital and medical services are only covered if they are completed by an in-network provider. However, there are some services that have out-of-network coverage so you could see an out-of-network provider for that service and have coverage. However, the services that fall out-of-network will vary with each plan.

There are technically 4 Medicare Parts. Part A is hospital coverage, Part B is medical coverage, Part D is prescription drugs, and Part C is the Medicare Advantage plans. Easy way to think about Part C is that it most often incorporates A, B and D into one plan.

No, Medicare is not completely free in 2025; while most people will not pay a premium for Part A (hospital insurance), they will still have to pay a monthly premium for Part B (medical insurance), which is set at $185 per month in 2025; additionally, there will be deductibles and copayments associated with both parts depending on the services used. 

Key points about Medicare costs in 2025:

• Part A (Hospital Insurance): Most people will not pay a premium for Part A due to their work history, making it essentially “free” for them. 
• Part B (Medical Insurance): The standard monthly premium for Part B in 2025 is $185. 
• Income-related adjustments: Some individuals with higher incomes may have to pay a higher Part B premium based on their modified adjusted gross income.
• Medicare 2025 Part B premiums by Income

IRMAA can significantly increase your Medicare costs, especially if your income is close to the next tier. Planning ahead is essential to avoid unexpected premium hikes. For example:

• A single filer with MAGI of $165,001 will pay an additional $329 per month for Part B compared to someone just below the threshold. 
• If your income decreases significantly in2023 due to returement or other changes, you can appeal IRMAA by filing Form SSA-44 to request a new determination. 

Tips to Manage IRMAA Costs

1. Adjust your MAGI: Consider contributing to a Health Savings Account (HSA) or other tax-advantage accounts to lower your taxable income. 
2. Appeal When Necessary: If your income changes due to a qualifying life event (e.g. retirement, divorce, or loss of income), appeal your IRMAA determination.
3. Review Investments: Capital gains from selling assets can push you into a higher IRMAA tier. Plan asset sales strategically. 
4. Work with a Financial Advisor: A professional can help you develop a tax strategy to minimize IRMAA exposure. 

Yes. We offer free consultations for individuals and families in Tucson, Pima County, and across Southern Arizona to help you understand your options before choosing a policy.

Independent agencies can compare policies from multiple carriers, helping clients find coverage that fits their situation rather than a one-size-fits-all solution.