We encourage you to scroll through this list of questions individuals have asked us when first enrolling in Medicare or thinking about changing their plan:
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Q: If I change my Medicare Advantage plan, will I have to change my doctors? and How will I know if my doctor accepts a particular company’s plan?
A: No one likes having to change find new doctors. That’s why your agent will help with confirming which Medicare Advantage company has an “in-network” contract with your primary care and specialist providers.
Q: Explain the Late Enrollment Penalty and how do make it go away
A: A Medicare late enrollment penalty is an extra fee added to your monthly Medicare Advantage or Part D premium because you did not sign up for coverage when you were first eligible. This fee usually lasts for as long as you have Medicare. The cost depends on which part of Medicare you delayed You can request a waiver or removal of a Medicare late enrollment penalty through an official appeal if you had qualifying creditable coverage, received incorrect official misinformation, or qualify for financial assistance like Extra Help.
Q: Will I need a referral from my primary care doctor to see a specialist?
A: That depends. Generally, HMO plans require you obtain a referral from your primary care provider before seeing a new specialist. Most PPO plans allow you to directly schedule your own specialist visits. However, as some company plans are exceptions to this, check with your agent and confirm.
Q: How is a Medicare Advantage HMO different from a PPO plan?
A: Other than in the case of emergency or urgent care, when enrolled in an HMO plan you are required to use an “in-network” provider. PPO plans, too, have a network of Preferred Providers (thus PPO) and also permit you to visit other providers who may agree to accept your coverage but on an “out-of-network” basis. HMO or PPO, you’re still covered; it’s just that your cost sharing or copay responsibility is usually lower with an “in-network” provider and greater when seeing an “out-of-network” provider.
Q: Will my Medicare Advantage plan include dental, eyewear and hearing aid coverage?
A: Many do, as an added plan benefit. Your agent can help with comparing how much allowance each Medicare Advantage company offers for dental, eyewear and hearing aid.
Q: When can I change my plan?
A: With Medicare Advantage, you can change your plan annually during the Annual Enrollment Period and new coverage will take effect January 1 of the next year. Otherwise, under special circumstances, you may be eligible for a Special Enrollment Period which allows you to change your Medicare Advantage or Standalone Part D coverage.
Q: What is New York EPIC?
A: If you are New York State resident, enrolled in Medicare Advantage with Part D drug coverage or have a standalone Part D plan, are age 65 or older, not enrolled in Medicaid with annual taxable income below the limit ($100k couple / $75k individual) you may be eligible for secondary drug coverage through EPIC. (EPIC Members are also eligible for one Special Enrollment Period annually ) Visit New York State site [apply online]
Q: Does my Medicare plan include coverage while traveling?
A: The exact details are outlined in the Evidence of Coverage document for your specific Medicare Advantage plan however, most plans cover worldwide emergency and urgently needed services outside the United States under certain circumstance. Transportation back to the United States is not covered.
Q: Please explain the two “Out of Pocket” cost caps.
A: MOOP (Maximum Out-of-Pocket) caps your yearly spending on medical services (Part A and Part B) under Medicare Advantage. With a PPO plan, you will see that level expressed for both in-network and combined in/out of network spending. TrOOP (True Out-of-Pocket) is the annual maximum for Part D drug costs. That amount includes any deductible and copays for covered drugs filled at a pharmacy. In 2026, your spending on Part D drugs is capped at $2,100, after which you pay $0 for covered drugs.
Q: What is Prior Authorization, how does it work and who is responsible for getting this done?
A: Prior authorization is a rule where your doctor must get approval from your Medicare Advantage plan before it covers a specific test, treatment or service. Nearly all private Medicare Advantage plans use prior authorization to manage costs and care. Standard requests must be decided within 7 days, and urgent requests within 72 hours. If a plan denies a request, they must give a specific reason and instructions on how to appeal. The healthcare provider is responsible for seeking and submitting the prior authorization request.
If you see an out-of-network provider, you face a much higher risk. While the provider still must supply the medical records, you are ultimately responsible for ensuring the authorization is approved before receiving care, or you may have to pay the entire bill yourself.
Your role is to act as an advocate. You should always contact your Medicare Advantage plan or check your plan’s portal to verify that your doctor’s request was actually received, processed, and approved before your appointment.
Q: I understand insulin is covered through Medicare and is not subject to a Part D deductible, however how are my diabetic supplies covered?
A: Medicare Advantage insurance companies cover diabetic supplies through a combination of medical (Medicare Part B) and prescription drug (Medicare Part D) benefits. For blood glucose monitors, the most significant difference between plans is which manufacturer they have selected as “preferred.” Using a non-preferred brand typically requires prior authorization and results in higher costs. Continuous glucose monitors (CGMs) are generally billed as Durable Medical Equipment (DME) and often require prior authorization.
> All diabetic supplies billed under Medicare Part B (medical) count toward your plan’s Maximum Out-of-Pocket (MOOP) limit. Once you hit this annual threshold (which differs, depending on the plan), you pay $0 for all covered medical diabetic supplies for the rest of the year. Supplies billed through Part D (pharmacy) follow separate drug coverage rules and stages
Q: Am I required to use mail order pharmacy?
A: Whether your medications are covered through a Medicare Advantage or standalone Part D drug plan, you will want to confirm that your favored retail pharmacy is “preferred” with the plan. Your drug costs may be reduced by using the plan’s preferred pharmacy. Most plans also include a mail order pharmacy option which offers convenience and possibly reduced cost sharing. Speak with your agent about each plan’s preferred retail and mail order pharmacies.
Q: If I want to leave a Medicare Advantage plan, return to Original Medicare and add a Medicare Supplement (aka Medigap) plan, what if I have pre-existing conditions?
A: It is true that after your Initial Enrollment Period, Medicare Supplement plans may not pay benefits during the first 6 months of coverage for pre-existing conditions. However, for residents of New York State replacing qualified insurance coverage, that 6 month exclusion does not apply.
IRMAA (Income-Related Monthly Adjustment Amount [for more info]
Medicare and You 2026 [download official handbook]
MSP (Medicare Savings Program) [for more info]
Part B (How to Enroll)
Privacy Policy [download our policy document]
Star Ratings
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