FAQ
FREQUENTLY ASKED QUESTIONS
Medicare Basics
A: Medicare is the federal health insurance program administered by the Centers for Medicare & Medicaid Services. Most Americans qualify at age 65 if they or their spouse worked and paid Medicare taxes for at least 10 years — that's 40 quarters. You also qualify under 65 if you've been receiving Social Security Disability Insurance for 24 months, or if you have ALS or End-Stage Renal Disease, which don't require the waiting period.
What surprises people is that Medicare isn't automatic for everyone. If you're already collecting Social Security benefits when you turn 65, you'll be enrolled in Parts A and B automatically. If you're not yet collecting Social Security — which is increasingly common as people delay benefits to maximize their payout — you need to actively enroll. Missing that window has consequences that follow you for years. Knowing which category you fall into is the very first step.
A: Think of it in layers.
Part A is hospital insurance. It covers inpatient hospital stays, skilled nursing facility care following a qualifying hospital stay, hospice care, and some home health services. Most people pay no premium for Part A if they've worked long enough, but it comes with a deductible of $1,736 per benefit period in 2026 and cost-sharing for longer hospital stays.
Part B is medical insurance. It covers outpatient care — doctor visits, preventive services, lab work, imaging, durable medical equipment, and outpatient surgery. Part B has a standard monthly premium of $202.90 in 2026 for most people, a $283 annual deductible, and then you pay 20% of Medicare-approved costs after that. There is no annual cap on that 20% in Original Medicare alone, which is why supplemental coverage matters so much.
Part C is Medicare Advantage — private plans offered by insurance companies that contract with Medicare to replace Parts A and B. I cover those in detail in a separate section below.
Part D is prescription drug coverage — standalone plans that work alongside Original Medicare and Medigap, or integrated into most Medicare Advantage plans.
A: Your Initial Enrollment Period is seven months long. It starts three months before your 65th birthday month, includes your birthday month, and extends three months after. Enrolling during the three months before your birthday month means your coverage starts the first day of your birthday month. The later you enroll within that window, the later your coverage starts.
If you miss your Initial Enrollment Period and don't have qualifying coverage from a current employer, the consequences are significant. For Part B, you'll pay a 10% premium surcharge for every 12-month period you were eligible but didn't enroll — and that penalty is permanent, added to your Part B premium for life. For Part D, the penalty is 1% of the national base beneficiary premium for every month you went without creditable drug coverage, also permanent.
There are exceptions. If you're still working at 65 and covered by an active employer plan from a company with 20 or more employees, you can delay Medicare without penalty and enroll during a Special Enrollment Period when that coverage ends. That distinction is critical and getting it wrong in either direction — enrolling too early or too late — costs money.
A: A Special Enrollment Period is a window outside of standard enrollment periods that allows you to make Medicare coverage changes because of a qualifying life event.
The most common triggers are losing employer-sponsored coverage, moving to a new service area where your current plan is not available, losing Medicaid eligibility, gaining or losing Extra Help for Part D costs, and your plan leaving the market or losing its Medicare contract.
For people transitioning from employer coverage to Medicare — one of the most common situations I help with in Florida — the SEP gives you 8 months from the date your employer coverage ends to enroll in Medicare without penalty. That sounds like plenty of time, but people consistently underestimate how much planning is required to get into the right supplemental coverage alongside Parts A and B. I recommend starting those conversations at least 90 days before your employer coverage ends, not 90 days after.
A: The Annual Enrollment Period runs from October 15 through December 7 every year, with any changes taking effect January 1. It is the primary window most Medicare beneficiaries have to make plan changes each year.
During AEP you can switch from Original Medicare to a Medicare Advantage plan, switch from Medicare Advantage back to Original Medicare, switch from one Medicare Advantage plan to another, and join, switch, or drop a Part D prescription drug plan.
What you cannot do during AEP is switch Medicare Supplement plans with guaranteed approval in most states — including Florida. Medigap has its own separate rules and its own separate window, which is one of the most misunderstood aspects of the entire Medicare system. Getting into the right Medigap plan from the start, when you have guaranteed-issue rights, is fundamentally more important than the annual plan shopping that AEP enables for Advantage and Part D.
There is also a Medicare Advantage Open Enrollment Period from January 1 through March 31 each year, during which people already enrolled in a Medicare Advantage plan can make one switch — either to a different MA plan or back to Original Medicare.
Medicare Costs
A: The honest answer depends on several factors, but here is the baseline.
Part A: $0 premium for most people who worked 40 or more quarters. If you worked 30 to 39 quarters the premium is $284 per month. Fewer than 30 quarters and it is $518 per month. The Part A deductible is $1,736 per benefit period — not per calendar year.
Part B: The standard premium is $202.90 per month in 2026 for individuals with income at or below $106,000 and married couples filing jointly at or below $212,000. Higher earners pay more through IRMAA surcharges, which I cover in a separate question below.
Part D: Varies by plan. Florida has competitive Part D pricing — standalone premiums in many counties start well under $30 per month, though the right plan for you depends entirely on your specific medications, not the premium.
Medicare Supplement: In Florida, Plan G premiums for a 65-year-old typically range from roughly $120 to $180 per month depending on the carrier and county, with High Deductible Plan G often coming in between $40 and $70 per month. Florida uses attained-age rating, meaning premiums increase as you get older.
Medicare Advantage: Many plans in Florida offer $0 premiums, though you always continue paying your Part B premium of $202.90 per month regardless of which plan you are on. That Part B premium is non-negotiable — it is often the biggest hidden cost people overlook when they see a $0 Medicare Advantage premium advertised.
A: IRMAA stands for Income-Related Monthly Adjustment Amount. It is a surcharge applied to your Medicare Part B and Part D premiums if your income exceeds certain thresholds. In 2026, the surcharge begins for individuals with a Modified Adjusted Gross Income above $106,000, or married couples filing jointly above $212,000. The surcharge is based on your income from two years prior — so your 2026 IRMAA is calculated from your 2024 tax return.
IRMAA affects more people than most expect, particularly in Florida communities with strong ties to the New York market. Home sales, Roth conversions, required minimum distributions, and one-time income events can push someone into an IRMAA bracket for a single year even if their income is normally well below the threshold.
The important thing to know is that IRMAA is appealable. If your income has dropped since the year used to calculate your surcharge — due to retirement, divorce, death of a spouse, or other life-changing events — you can file Form SSA-44 with the Social Security Administration to request a lower premium based on your current income. I help clients navigate this process regularly. It is one of the areas where working with an informed Medicare broker rather than just an insurance salesperson makes a meaningful financial difference.
A: Original Medicare by itself has no annual out-of-pocket maximum. That is the single most important cost fact most people do not fully understand until they need significant care.
In 2026, here is what you are exposed to without supplemental coverage: the Part A deductible of $1,736 per benefit period — not per year, meaning a second hospitalization more than 60 days after the first triggers a second full deductible. Part B costs you 20% of every Medicare-approved service with no cap whatsoever. A $100,000 course of cancer treatment leaves you with $20,000 in coinsurance. A major cardiac event with multiple hospital stays can generate multiple Part A deductibles in a single year. Skilled nursing facility stays beyond day 20 cost $217.50 per day through day 100, after which Medicare stops contributing entirely.
People who hear "Medicare covers 80%" assume they are well protected. They are — up to a point. But 20% of serious illness costs in the modern healthcare system is not a small number, and there is no ceiling on it in Original Medicare alone. This is the core case for supplemental coverage of some kind, whether that is Medigap or the out-of-pocket maximum structure built into Medicare Advantage plans.
A: Starting in 2025 and continuing in 2026, Medicare beneficiaries have a $2,100 annual out-of-pocket cap on Part D prescription drug costs. This is one of the most significant improvements to Medicare in years and it eliminates what was previously called the coverage gap — commonly known as the donut hole — which caused beneficiaries to face dramatically higher drug costs after reaching a certain spending threshold mid-year.
Here is how it works in practice: once your out-of-pocket spending on covered Part D drugs reaches $2,100 in a plan year, your cost-sharing for covered drugs drops to $0 for the remainder of the year. There is also a Medicare Prescription Payment Plan option that lets you spread your out-of-pocket drug costs across monthly installments throughout the year rather than paying large lump sums at the pharmacy when you first fill expensive prescriptions.
This cap applies to standalone Part D plans and to Medicare Advantage plans with integrated Part D coverage. It is particularly meaningful for beneficiaries on expensive specialty medications, insulin-dependent diabetics, and anyone with multiple chronic conditions requiring brand-name drugs. If you or someone you know was previously devastated by donut hole costs, the current rules have fundamentally changed that situation.
A: The Part B Excess Charge is a lesser-known cost exposure that catches people off guard. Medicare sets an approved rate for every covered service. Doctors and providers who accept assignment agree to accept that rate as payment in full. However, doctors who do not accept assignment can charge up to 15% above Medicare's approved rate — that extra 15% is the excess charge, and Original Medicare does not cover it.
Not every provider charges excess fees, and in Florida the vast majority of physicians do accept Medicare assignment. But it is not universal, and certain specialists — particularly in high-demand fields — sometimes operate on a non-participating basis.
The clean protection against excess charges is Medigap Plan G. Plan G covers 100% of Part B excess charges. Plan N does not cover them. High Deductible Plan G covers them once you have met the $2,950 annual deductible. If you are considering a plan that does not cover excess charges, it is worth verifying whether your specific physicians and specialists accept assignment before finalizing that decision. I do that verification as a standard part of every consultation.
Medicare Advantage
A: Medicare Advantage — formally known as Medicare Part C — is a private insurance alternative to Original Medicare. Instead of receiving your Part A and Part B benefits directly from the federal government, you receive them through a private carrier that contracts with Medicare. The carrier is required to cover everything Original Medicare covers, and most plans add benefits Original Medicare does not — dental, vision, hearing, gym memberships, over-the-counter allowances, transportation, and more.
Florida has one of the highest Medicare Advantage enrollment rates in the country, and the reasons are straightforward: strong carrier competition drives down premiums and drives up benefits, the population skews toward younger and healthier new retirees, and the sheer volume of $0 premium options is genuinely attractive to people on fixed incomes.
What I tell people in Florida is that Medicare Advantage is a legitimate and often excellent choice — for the right person. But the right person needs to understand the tradeoff. You gain extra benefits and lower monthly costs in exchange for provider networks, copays, prior authorization requirements, and an annual plan structure that can change significantly from year to year. For someone who stays healthy, sees a small number of in-network doctors, and does not need complex specialty care, MA can deliver outstanding value. That calculation changes meaningfully when health complexity increases.
A: Both are Medicare Advantage plans but they handle provider access very differently.
An HMO — Health Maintenance Organization — requires you to use doctors and hospitals within the plan's network for all non-emergency care. You typically need a referral from your primary care physician to see a specialist. HMOs generally have lower premiums and lower copays within the network, but if you go outside the network for anything other than a true emergency, the plan typically will not pay and you are responsible for the full cost.
A PPO — Preferred Provider Organization — gives you more flexibility. You can see in-network providers at lower cost-sharing, but you can also see out-of-network providers and the plan will still contribute — just at a higher cost-sharing level. PPOs generally do not require referrals for specialists. The tradeoff is that PPO plans often carry higher premiums than comparable HMOs.
For snowbirds and people who split time between Florida and New York — which is a meaningful portion of the people I work with — this distinction is particularly important. Most Florida HMOs cover out-of-state care for emergencies only. A PPO gives you more coverage for routine care when you are traveling or spending time in another state. But even for PPO plans, out-of-network cost-sharing can be substantial. For people who genuinely divide their time between two states, I typically recommend exploring Medigap carefully before defaulting to a Florida-based MA plan.
A: You look it up — but do not rely solely on the plan's online directory, because those directories are frequently outdated.
Here is the verification process I use for every client. First, check the plan's online provider directory using the specific plan name and plan year, not just the carrier name. Second, call your doctor's office directly and ask whether they are currently accepting patients on that specific plan — not just whether they accept Medicare in general, and not just whether they appear in the directory. Directories can lag by months. A physician may have left a network in January and still be listed in March.
Third — and this matters particularly in Florida — confirm that the facility where your doctor performs procedures and surgeries is also in-network. A physician can be in-network but operate at a hospital that is not, and your cost-sharing can be dramatically different depending on where the service is actually delivered.
I run this verification for every client before recommending a Medicare Advantage plan. It takes time. It sometimes means a plan that looked perfect on paper gets crossed off the list. But it is the only way to actually know whether a plan works for your specific situation — not just how it looks in a brochure.
A: Prior authorization is a requirement in many Medicare Advantage plans that your doctor must obtain approval from the insurance company before you can receive certain services, medications, procedures, or specialist referrals. The carrier reviews whether the treatment meets their definition of medical necessity before agreeing to cover it.
Original Medicare does not require prior authorization for most services. Medicare Advantage plans do — and the scope and frequency of prior authorization requirements varies significantly from plan to plan and carrier to carrier.
This matters because prior authorization can delay care. Denials — even when eventually overturned on appeal — add time, stress, and administrative burden during moments when you need to be focused entirely on your health. CMS has tightened prior authorization rules for Medicare Advantage in recent years and the landscape is improving, but prior authorization has not been eliminated. Before recommending a Medicare Advantage plan, I look at the plan's prior authorization requirements for the types of services most relevant to your specific health profile. If you manage a complex condition or see specialists regularly, this is not a minor consideration.
A: This is one of the most common calls I receive every fall, and the answer is that you have options — but you need to act during the Annual Enrollment Period between October 15 and December 7.
During AEP you can switch to a different Medicare Advantage plan with better benefits or lower costs in your area. You can also switch back to Original Medicare and explore pairing it with a Medigap plan — though this is where it gets complicated in Florida. If you left Original Medicare to enroll in Medicare Advantage and now want to switch back to Medigap, that triggers medical underwriting in Florida, meaning the Medigap insurer can review your health history and may decline you or charge higher premiums based on pre-existing conditions. This is one of the primary reasons I emphasize getting the initial plan decision right — because the exits are not always clean.
The October review of your Annual Notice of Change — the ANOC document your plan is required to send you each fall — is one of the most important pieces of mail you will receive all year. Read it carefully. If your plan is changing in ways that affect your doctors, your drugs, or your cost-sharing, that is your signal to call me and do a full market comparison before the December 7 deadline.
Medicare Supplement (Medigap)
A: A Medicare Supplement plan — commonly called Medigap — is a private insurance policy that fills in the cost gaps that Original Medicare leaves. The name is literal: it supplements Medicare rather than replacing it.
Here is how the mechanics work. When you receive a covered service, Medicare pays its share first — generally 80% of approved costs after your deductibles are met. Your Medigap plan then pays its share according to the plan's benefit structure. For Plan G in 2026, after you have paid the Part B deductible of $283, the plan covers essentially everything else Medicare approves — the 20% coinsurance, Part A deductibles, hospital copays for extended stays, skilled nursing facility coinsurance through day 100, and Part B excess charges. You receive care, Medicare processes the claim, and the Medigap insurer covers the remainder. In most cases you pay nothing at the point of service beyond that annual deductible.
What Medigap does not cover: routine dental, vision, hearing, prescription drugs, or long-term custodial care. For prescriptions you need a separate standalone Part D plan. The tradeoff for comprehensive medical coverage is the monthly Medigap premium — but for people who want complete predictability in their healthcare costs and the freedom to see any Medicare-accepting provider anywhere in the country, it is frequently worth it.
A: Plan G is the most comprehensive Medigap plan available to new enrollees since Plan F was closed to beneficiaries who became Medicare-eligible after January 1, 2020. The only gap Plan G leaves is the Part B deductible — $283 in 2026. That is a modest exposure in exchange for meaningfully lower premiums than legacy Plan F, which is why Plan G has become the default recommendation for most new enrollees who want comprehensive coverage.
What distinguishes Plan G from current alternatives: compared to Plan N, Plan G covers Part B excess charges — Plan N does not — and Plan G carries no $20 office visit copay or $50 emergency room copay that Plan N includes. For people who see specialists frequently or whose physicians do not accept assignment, Plan G's cleaner coverage justifies the premium difference.
Compared to High Deductible Plan G, standard Plan G offers lower annual exposure. You pay the $283 Part B deductible and then nothing else on Medicare-approved services for the rest of the year. HD Plan G requires you to pay up to $2,950 in combined Medicare cost-sharing before the plan kicks in fully, but in exchange the monthly premium is dramatically lower. For a healthy 65-year-old, the math on HD Plan G often favors lower total annual costs. For someone with known health conditions or frequent healthcare utilization, standard Plan G's predictability is usually the right call. I walk through both scenarios with actual numbers for every client.
A: High Deductible Plan G is a Medigap option that provides identical coverage to standard Plan G — covering everything Medicare approves — but only after you have met a combined annual deductible of $2,950 in 2026. Until you reach that threshold, you pay your standard Medicare cost-sharing out of pocket. Once you hit $2,950, coverage engages exactly as standard Plan G operates, covering 100% of remaining Medicare-approved costs for the year.
The premium difference is significant. Where standard Plan G in Florida might run $130 to $180 per month for a 65-year-old depending on carrier and county, High Deductible Plan G often comes in between $40 and $70 per month. That is a difference of $720 to $1,680 per year in premiums alone. If you stay healthy and your total Medicare cost-sharing for the year falls well below $2,950, you come out ahead — sometimes dramatically ahead.
The calculation I work through with clients is straightforward: if your expected annual medical utilization is low and your primary concern is catastrophic protection rather than first-dollar coverage, HD Plan G gives you exactly that protection at a much lower monthly cost. It pairs particularly well with a Health Savings Account if you are still working and HSA-eligible.
The important caveat is that HD Plan G is not right for everyone. Someone managing multiple chronic conditions with frequent hospitalizations, regular specialist visits, or expensive outpatient procedures should think carefully about whether the $2,950 annual exposure is comfortable. I help clients model both plans with realistic utilization scenarios so the decision is based on math, not guesswork.
A: No — and this is one of the most consequential differences between Florida and states like New York that former New Yorkers moving to the Treasure Coast and South Florida need to fully understand.
New York has guaranteed-issue Medigap protections that allow residents to enroll in or switch a Medigap plan at any time of year, without medical underwriting and without being declined for health reasons. Florida does not have this protection. Outside of your six-month Initial Enrollment Period at age 65 and a limited set of qualifying Special Enrollment Periods, Florida Medigap insurers can apply full medical underwriting — reviewing your health history and declining you or charging significantly higher premiums based on pre-existing conditions.
This makes the initial Medigap enrollment decision in Florida considerably more consequential than it is in New York. If you get into the wrong plan at 65, or choose a carrier with poor rate stability history and want to switch at 70, you may find that health developments since your initial enrollment have narrowed your options substantially. I have worked with clients in their mid-70s who wanted to switch Medigap plans and found it significantly more complicated than they anticipated.
The practical guidance: get into the right Medigap plan from the start, choose a carrier with a documented record of stable rate increases, and work with a broker who understands both the Florida and New York markets if you have ties to both. Getting this decision right the first time is far easier than correcting it later.
A: This is exactly the right question to ask, and most people do not ask it. They see that Plan G benefits are standardized across carriers, pick the lowest current premium, and assume they have made the optimal choice. The benefits are standardized. The carriers are not, and the differences between them matter over a 20-year time horizon.
The factors that meaningfully differentiate Medigap carriers when the plan letter is identical:
Current premium — what you pay in year one. Rate stability history — how much the carrier has increased premiums over the past five to ten years. A carrier with a lower starting premium but a history of 8 to 10% annual increases may cost you significantly more by age 75 than a carrier with a slightly higher starting premium and consistent 3 to 4% annual increases. This long-term view is the analysis most agents never show you.
Claims payment reputation — how efficiently and reliably the carrier processes and pays claims. Household discounts — many carriers offer 5 to 12% premium discounts when two people in the same household hold policies with the same carrier. Financial strength rating from agencies like A.M. Best — for a product you may hold for 20 or more years, the carrier's long-term financial stability matters. I compare carriers across all of these dimensions for every Medigap recommendation, not just the premium line on day one.
Medicare Part D
A: Yes — and the reason is the late enrollment penalty.
Part D has a penalty structure similar to Part B. If you go without creditable drug coverage for 63 or more consecutive days after you are first eligible for Part D, you pay a permanent premium surcharge when you eventually enroll. The penalty is 1% of the national base beneficiary premium for every month you went without coverage, and it stays with you for as long as you have Part D — permanently.
For someone who genuinely takes no medications at 65, a low-premium standalone Part D plan — in many Florida counties options are available under $15 to $20 per month — is inexpensive insurance against both that penalty and against the unpredictability of future drug needs. You do not know what medications you will need at 72 or 78. Enrolling in Part D at 65 costs very little and eliminates the penalty risk entirely.
The one exception: if you have creditable drug coverage from another source — an active employer plan, VA benefits, or TRICARE — that coverage satisfies the requirement and you can delay Part D enrollment without penalty. I verify creditable coverage status in every consultation before making a Part D recommendation.
A: The only reliable way is to run your actual medication list through each available plan's formulary and compare total estimated annual costs — not just monthly premiums.
Here is why premium-first comparison fails consistently: a plan with a $14 monthly premium may place your most expensive medication in Tier 4 or Tier 5, resulting in $200 to $400 per fill at the pharmacy. A plan with a $48 monthly premium may cover that same medication at Tier 2 for $15 per fill. Over 12 months the nominally more expensive plan saves you thousands of dollars. The premium is the least important number in the Part D decision.
The tool that enables this comparison is Medicare's Plan Finder at medicare.gov. You enter your medications, dosages, and preferred pharmacy and it calculates estimated annual costs across every plan available in your zip code, ranked from lowest to highest total cost. I run this analysis for every client with Part D needs. It takes 20 to 30 minutes and has saved clients hundreds to thousands of dollars annually by identifying the right plan rather than the cheapest-looking one.
Formularies change every year. A medication that is Tier 2 this plan year may move to Tier 4 next year. Reviewing your Part D plan annually during AEP is not optional — it is the mechanism that ensures the plan you have continues to make financial sense for the drugs you are actually taking.
A: The coverage gap — historically called the donut hole — was a phase of Part D where beneficiaries faced dramatically higher out-of-pocket drug costs after reaching a certain spending threshold mid-year. For people on expensive medications it created significant and sometimes devastating financial pressure.
As of 2025 and continuing in 2026, the donut hole has been effectively eliminated. The annual out-of-pocket cap for Part D is now $2,100. Once your out-of-pocket spending on covered Part D drugs reaches $2,100 in a calendar year, your cost-sharing drops to $0 for the remainder of the year. There is no gap phase, no dramatically higher mid-year costs, and no ceiling above that $2,100 threshold.
There is also a Medicare Prescription Payment Plan option that allows you to spread your out-of-pocket drug costs across equal monthly installments throughout the year rather than paying large amounts at the pharmacy when you first fill expensive prescriptions in January or February. This is particularly valuable for beneficiaries whose most expensive fills come early in the year before they have spread their spending across many months.
A: It depends on the plan, and the answer affects your out-of-pocket costs in ways that are easy to overlook.
Every Part D plan maintains a network of preferred and non-preferred pharmacies. Using a preferred pharmacy within the network typically means lower copays and cost-sharing on your medications. Using a non-preferred network pharmacy means higher copays for the same drugs. Using a pharmacy entirely outside the plan's network may mean paying full retail cost with no plan contribution at all.
Most major national chains — CVS, Walgreens, Walmart, and Publix here in Florida — are in-network for the majority of Part D plans. However, preferred status varies by plan, and some plans build their preferred pharmacy networks around specific chains. If your preferred pharmacy is not among the preferred tier for a particular plan, your out-of-pocket drug costs will be higher than the plan's advertised copays suggest.
Mail-order pharmacy is worth understanding as well. Most Part D plans offer 90-day supplies through mail-order at lower cost per fill than retail 30-day supplies for maintenance medications. If you take the same medications every month, the economics of mail-order are often compelling and the convenience is significant — particularly for people who split time between Florida and another state.
A: Standalone Part D plans are not geographically restricted the way Medicare Advantage HMO networks are for medical care. Your Part D coverage follows you anywhere in the United States — you can fill prescriptions at a Walgreens in New York, a CVS in Arizona, or a pharmacy in Georgia and your plan applies the same coverage as if you were home in Port St. Lucie, as long as the pharmacy is within your plan's network.
The practical consideration for snowbirds and frequent travelers is confirming that your preferred pharmacy chain has locations in the areas where you spend extended time and that those locations carry preferred status in your plan's network. Most national chains do, but it is worth verifying. Mail-order pharmacy services are particularly valuable for people who divide their time between states — a 90-day supply shipped to your current address eliminates the need to locate a specific pharmacy in an unfamiliar area every month.
This geographic flexibility is one of the meaningful advantages Part D has over Medicare Advantage HMO networks for multi-state living. If seamless nationwide coverage for both medical care and prescriptions is a priority, a Medigap plan paired with a standalone Part D plan provides exactly that with no network restrictions on either side.
Medicare Myths
A: This is one of the most dangerous myths in Medicare and it costs people real money every year — sometimes tens of thousands of dollars in a single health event.
Original Medicare covers a great deal, but not everything, and not without significant cost exposure. There is no annual out-of-pocket maximum in Original Medicare alone. The 20% Part B coinsurance has no ceiling. The Part A deductible of $1,736 resets with each benefit period — a second hospitalization more than 60 days after the first triggers a second full deductible. Skilled nursing facility stays beyond day 20 cost $217.50 per day through day 100, after which Medicare stops contributing entirely. And Medicare does not cover routine dental care, routine vision, hearing aids, or long-term custodial care under any circumstances.
The people who hold this belief tend to discover its inaccuracy during a serious illness, when the bills arrive and the 20% they assumed was a minor number turns out to be $15,000 or $30,000 or more. Supplemental coverage — whether Medigap or the out-of-pocket maximum structure of a Medicare Advantage plan — exists precisely to prevent that outcome. For most Medicare beneficiaries it is not optional extra coverage. It is a financial necessity.
A: Premium is one number in a much larger equation, and optimizing for it alone is one of the most reliable paths to ending up in the wrong plan.
The total cost of a Medicare plan includes the monthly premium, deductibles, copays for primary care and specialist visits, coinsurance for procedures and hospitalizations, the annual maximum out-of-pocket for Advantage plans, drug costs under your specific formulary, and the financial consequences of being unexpectedly out of network when you need care.
A $0 premium Medicare Advantage plan with a $9,250 maximum out-of-pocket and $350 per day hospital copays after day four is not necessarily cheaper than a plan with a $65 monthly premium and a $4,000 maximum out-of-pocket. Depending on how much care you use in a given year, the plan with the visible monthly cost may save you thousands compared to the one that appeared free.
The same logic applies to Medigap. A plan with a lower current premium from a carrier with a history of aggressive annual rate increases may cost more by age 73 than a plan with a modestly higher starting premium from a carrier with a stable rate history. I model this comparison over five to ten years for clients, not just year one, because that is the timeframe over which the decision actually plays out.
A: This depends on the plan type, and the nuances matter enormously — particularly in Florida.
For Medicare Advantage and Part D, you have defined windows: the Annual Enrollment Period from October 15 through December 7 each year, and the Medicare Advantage Open Enrollment Period from January 1 through March 31 for Advantage-only changes. Outside those windows, plan changes require a qualifying Special Enrollment Period triggered by a specific life event. You cannot simply decide in May that you want a different Medicare Advantage plan and make the switch.
For Medigap — and this is the version of this myth with the most serious consequences — the switching rules in Florida are far more restrictive than most people assume, especially those accustomed to New York's rules. Outside of your Initial Enrollment Period at 65 and qualifying Special Enrollment Periods, Florida Medigap insurers can apply full medical underwriting. They can review your health history and decline you or charge significantly more based on pre-existing conditions.
The assumption that "I'll try this plan and switch if I don't like it" works in New York. It frequently fails in Florida. People who make their initial Medicare decisions casually, thinking they can always adjust later, sometimes find themselves locked into plans they want to leave but cannot exit on favorable terms because their health has changed. Understanding the switching rules before you enroll — rather than after you want to switch — is one of the most valuable things I provide.
A: The $0 premium refers only to the Medicare Advantage plan's own monthly charge on top of your Part B premium. You always continue paying your Part B premium — $202.90 per month in 2026 for most beneficiaries — regardless of which plan you are enrolled in. That payment does not go away when you join a Medicare Advantage plan and it is not optional.
Beyond the Part B premium, Medicare Advantage plans have their own cost-sharing structures that activate when you use care: copays for primary care visits, copays for specialist visits, coinsurance for outpatient procedures, daily copays for inpatient hospital stays, and an annual maximum out-of-pocket that in 2026 can be as high as $9,250 for in-network services. Once you reach that maximum the plan covers 100% of in-network costs for the rest of the year — but getting there is not free.
For someone who stays healthy and uses minimal care, a $0 premium Medicare Advantage plan can represent genuinely excellent value. The math looks very different for someone who experiences a significant health event — a hip replacement, a cancer diagnosis, a cardiac hospitalization — and finds themselves accumulating copays and coinsurance toward a several-thousand-dollar out-of-pocket maximum over the course of the year. A plan is not free because the premium line reads zero. Total annual cost is what you pay.
A: Your doctor can tell you which plans their practice currently accepts. They cannot tell you which plan is right for your overall financial situation, your drug coverage needs, your other providers and specialists, your travel habits, your risk tolerance, or your long-term cost exposure. Those are entirely different questions and most physicians are neither trained nor positioned to answer them.
What I see happen regularly is that a patient asks their doctor about Medicare, the doctor mentions that their practice accepts a particular carrier's plans, and the patient interprets that as a recommendation. The result is often a plan that works for that one physician relationship but fails in important other ways — a high out-of-pocket maximum, drug coverage that does not match the patient's formulary needs, a network that excludes the hospital where the patient's surgeon operates, or rate increases that make the plan expensive within a few years.
Your physician is a critical input into the plan selection process — particularly for network verification. But they are one input among many. A licensed independent broker looks at the full picture: your doctors, your drugs, your budget, your health complexity, your travel patterns, and the long-term economics of the decision. If you want to know which plans your doctor accepts, call their office. If you want to know which plan is right for you, call me.