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 Question:

I got a letter from Medicare (Centers for Medicare & Medicaid Services, CMS) saying that I might need to sign up for Medicare Part B. I have coverage through my employer, so do I still need to have Medicare Part B?

Answer:

According to data.cms.gov, over 68 million Americans are enrolled in Medicare. Each of those 68 million have slightly different circumstances that impact their Medicare enrollment decisions. Over half of those enrollees have Medicare Part A & B plus additional insurance, like Medicare Advantage Plans, Medicare Supplement Plans, or Medicare Part D drug plans. On the other hand, slightly less than half of those 68 million American’s have coverage through another source, like employee benefits.

The annual General Enrollment Period (GEP) runs from January 1 to March 31 and allows individuals an opportunity to sign up for Medicare Part B if they did not enroll when they should have. During the GEP, CMS sends letters like the one you received reminding people with only Part A that they MIGHT need to add Part B. This is mailed to them automatically, but not everyone who has Part A will need to add Part B.

To decide if you need Part B, there are a few questions to ask.

1. Did you qualify for Medicare based on age or disability?
2. If you qualified based on age, then the next question is: are you or your spouse currently an active, working employee at the workplace you receive your health benefits through?
3. If yes, then the last question is: are there at least 20 full-time employees at your employer’s workplace? If yes, then you should not be penalized for declining Part B. If there are fewer than 20 employees, or you not actively working for that employer, then you may be penalized if you do not add Part B.

Note that the only difference for when you qualify based on disability but have coverage through your spouse’s employer is that this employee number jumps to 100 minimum full-time employees instead of just 20.

Since you already had coverage through your employer, it sounds like you signed up for Part A only, you were actively working for your employer, and they had the correct minimum number of employees so you could avoid signing up for Part B without penalties. This was likely the ideal decision for you because Part A acts as secondary coverage to your employee benefits anytime you need hospitalization coverage.

However, as your letter from CMS suggests, maybe you do need to add Part B this year to avoid penalties. This could be due to retirement, or your group size has shrunk. If these or other situations apply, you need to understand what happens. If you should have applied for Part B earlier and didn’t there is a penalty for that period of time you are consider under-insured.

The penalty applies once you decide to add Part B, and it would be a 10% increase to your Part B Premium for each 12 consecutive months you were incorrectly without Part B. That means that if you missed your chance to sign up for Part B any time less than 12 full months ago, you would still NOT face any penalty. However, if you missed your chance between 12 and 24 months ago, then you’d be penalized at 10%­ – and if you missed your chance to sign up 24 months ago, you would be penalized with at 20%. Again, it’s a 10% for EACH consecutive 12-month period you missed. And that DOES increase per 12-month period, so if you missed your chance by 36 months, then it would be 30%, and so on.

That 10% is a percentage of the current Part B premium, which is $185. You’d pay an extra $18.50 per month, on top of the regular Part B premium of $185. So if you’re a year late signing up, then you pay $203.50 for your Part B instead of just $185. Remember this penalty is paid EVERY MONTH FOR THE REST OF YOUR LIFE. Plus if you’re 24 months, that 20% penalty becomes an extra $37 that you will have to pay monthly, $222 total, every month for the rest of your life. So even if the penalty does not sound too high to you, it quickly adds up, and you should consider your decision to sign up for Part B or not, very seriously.

Okay, let’s stay positive: Let’s assume you made the correct decision avoiding Part B. You had employee benefits through an employer of the right size, so no penalties, but now you’re ready to retire! Do you have to wait until the GEP in January-March? Luckily no, you’ll have a Special Enrollment Period (SEP) to leave your employer plan, add Part B without penalty, and add any needed additional Medicare coverage anytime! When you’re preparing to retire, it’s as simple as signing up for Part B, and then adding any other coverage that you wish. You can complete CMS form 40B to request the activation of Part B, and it will begin on the 1^st of the month after the completed form is received by Social Security Administration (SSA).

I hope this information clears up why you got that letter from CMS and also answers your question about needing Medicare Part B. Remember, you only have until March 31 if you NEED Medicare Part B and didn’t sign up earlier.

If you have questions or need assistance navigating your options, don’t hesitate to reach out to the Lawley Medicare Solutions Team. You can contact Medicare Service Team Lead Gabrielle Connor at 716.849.8223, or submit an inquiry through our contact form below. We’re here to help you find the right coverage for your needs!

At Lawley Medicare Solutions, our Medicare and Individual Health Consultants are dedicated to helping you make the most informed decisions about your healthcare needs. We offer personalized service and expert advice tailored to your unique situation. Contact us today by phone or email to schedule a consultation and ensure you’re getting the best coverage for your needs.

Read all Inside Medicare articles HERE.

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur. For questions, concerns, or to reach Lawley Medicare Solutions, call 716.849.8223.

 Question: My spouse just passed away, and I am so overwhelmed with all that needs to be done. Now I found out his retiree health insurance will no longer cover me. Now what do I do?

Answer:

I am so sorry for your loss. This is an especially difficult and stressful period of time for you. Now with the loss of your insurance, you have one more task to take to take care of. So, let’s talk about solutions.

Usually when you lose coverage in this situation, you will lose coverage at the end of the month. It is February, so you have until March 1^st to pick a replacement for that retiree coverage without a gap in coverage.

There are also times during which you can make certain changes to Medicare without penalties called Special Enrollment Periods (SEP). SEPs are made available by law for many different reasons, mostly when someone loses coverage in their area. Because your current plan is ending due to the death of your spouse, this is counted as an acceptable loss of coverage, so you are allowed to research and sign up for any Medicare products you wish. In your circumstance, your SEP lasts for 60 days after your coverage ends, so that would be all of March and April, but we really don’t want to wait – again your retiree coverage through your spouse will still terminate at the end of the February, so you would still have a coverage gap if you wait longer, but the SEP gives you flexibility and avoids penalties.

In general, changes in Medicare coverage go into effect no sooner than the 1^st of the upcoming month. So, if you sign up for a for a product in February, it would begin March 1^st, if you sign up in March it begins April 1, and so on. I would strongly encourage you to do something in February, so that when your coverage ends, you would go directly onto your new policy, with no gap in coverage at all.

In order to qualify for that retiree plan, you needed Part A & B of Medicare, and now you’ll need those same parts to pick additional coverage. To pick new coverage, we need to review all the alternatives. In Western New York, we have more than 60 different insurance options to add onto your Medicare A & B. Remember that in order to avoid penalties, you must also have Prescription Drug Coverage, which is not part of A&B, but you can pick up during this month and the rest of your SEP.

Last week we talked about resources available to you. To check available plans, you could first check www.medicare.gov. The site is designed to help you learn about, research, and enroll into everything Medicare. If you have used this website in the past, you can log back in and update your information. If you have not used the website, I would encourage you to try it out. If you are uncomfortable using the website, you can also call 1-800-MEDICARE to work with the customer service staff to help you through the options and alternatives. I really like the website because it allows us to ‘see’ the alternatives in screen, and I personally tend to learn easier if I can read it, so I often print out articles or pages I want to study.

The website collects the relevant data, your zip code, your pharmacy, your medications, and then sorts which plans work the best for your medications. But remember medications are only part of the answer. You need to be sure that the plan you choose works with your physicians, and your budget.

You can of course reach out to others for help with these alternatives as well. This could be just a family member who is more tech savvy than you who could help you with this website. It could be an agency who helps with Medicare, like Office for the Aging, or Southwestern Independent Living Center. Or it could even be an Insurance Broker who works with Medicare products locally.

At this point, you really have pathways: the first is add coverage to you Part A &B called Medicare Supplement Plan and a standalone Prescription Drug Plan. This pathway tends to be more expensive when it comes to monthly premiums, but it also works anywhere and it’s very comprehensive. Note this option is not “bundled,” so you would end up with 3 separate insurance cards, you Medicare ID card, one card for your Supplemental plan, one for your Prescription Drug Plan.

The second pathway is enrolling in a Medicare Advantage Plan. These include Preferred Provider Organizations (PPO), Health Maintenance Organization (HMO) and more. This alternative tends to be much lower with regard to premiums, but may be restrictive in where you are allowed to use it. Using this pathway, you would have one insurance card and you show it wherever you go.

Whatever you choose, it’s important that you do not put this off, and ideally should make your choice in February, so your new coverage can begin March 1^st.

I hope this is helpful information and please reach out for help during this difficult time.

If you have questions or need assistance navigating your options, don’t hesitate to reach out to the Lawley Medicare Solutions Team. You can contact Medicare Service Team Lead Gabrielle Connor at 716.849.8223, or submit an inquiry through our contact form below. We’re here to help you find the right coverage for your needs!

At Lawley Medicare Solutions, our Medicare and Individual Health Consultants are dedicated to helping you make the most informed decisions about your healthcare needs. We offer personalized service and expert advice tailored to your unique situation. Contact us today by phone or email to schedule a consultation and ensure you’re getting the best coverage for your needs.

Read all Inside Medicare articles HERE.

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur. For questions, concerns, or to reach Lawley Medicare Solutions, call 716.849.8223.

 Question: I am getting close to my 65th birthday, and wanted to understand Medicare. Could you direct me to some useful resources to begin this learning process?

Answer:

Turning 65 is one of those significant birthdays that we have during our lifetime. What you need for insurance before and after 65 can be very different. The rules are consistent for every individual, but how they impact your decision is unique. The answer is different for each individual.

There are some very useful resources out there to help you learn about Medicare. The first resource I will give you is www.medicare.gov. This website is the official website for Medicare. There are tools that help you to understand Medicare and all its parts (A, B, C & D). The website has useful links and videos you can access to help your learning process. It is up to date and accurate for the 2025 calendar year. It also has information relating to the many products that work along with Original Medicare (Part A & B) to help you get your Medicare coverage. Those other products include, but are not limited to, Medicare Part D, Medicare Advantage Plans (Part C), and Medicare Supplements. It also includes some information about Employee and Retiree Coverage, as well as Veterans Benefits, Champ VA, and Tricare for Life. Plus, there is a Search feature that allows you to search for particular information you may be curious about. You can even use the site to create an individual login, which can be VERY useful once enrolled in Medicare.

Another resource I would direct you to use is the Medicare Rights Center, which the public can access at www.medicarerights.org. To quote from their website, “The Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities through counseling and advocacy, educations programs and public policy initiatives.” It offers wonderful information on their website, including videos, free courses, newsletters, and educations events. They let you learn about Medicare as a beginner or as an expert. They even have a paid Medicare Interactive Pro series, which gives you very in-depth information about Medicare and the many product options available through it. They even have a helpline for people with Medicare who face problems with their coverage. I have personally reached out to their staff many times to help people with Medicare related problems.

A third resource which shouldn’t be overlooked is the Centers for Medicare & Medicaid Services (CMS) and their website www.cms.gov. CMS is the federal agency that oversees health coverage through Medicare, Medicaid, Children’s Health Insurance Program, and the Health Insurance Marketplace. Their website is ideal for individuals who want to do a deep dive into the regulations and rules relating to Medicare coverage. It contains pamphlets you can order about Medicare coverage. They also host trainings and provide educational material for all their insurance programs. The site even has interesting articles on the history of Medicare and Medicaid coverage.

Last but certainly not least, I am excited to offer you the opportunity to attend my weekly “Making Sense of Medicare” seminar. I am personally hosting these seminars to educate individuals who are approaching Medicare eligibility and want to learn the basics. The seminar is a 1.5-hour introductory lesson on Medicare. I break down Medicare basics, the different parts of Medicare, and how to enroll. I’ll also help you determine if you need to enroll into Medicare. I provide these free seminars as a personalized opportunity to learn Medicare in a small group setting. To get a schedule of where and when these are being held, you can reach out to Lawley Insurance at 716-489-2988, or click here to learn more.

If you have questions or need assistance navigating your options, don’t hesitate to reach out to the Lawley Medicare Solutions Team. You can contact Medicare Service Team Lead Gabrielle Connor at 716.849.8223, or submit an inquiry through our contact form below. We’re here to help you find the right coverage for your needs!

At Lawley Medicare Solutions, our Medicare and Individual Health Consultants are dedicated to helping you make the most informed decisions about your healthcare needs. We offer personalized service and expert advice tailored to your unique situation. Contact us today by phone or email to schedule a consultation and ensure you’re getting the best coverage for your needs.

Read all Inside Medicare articles HERE.

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur. For questions, concerns, or to reach Lawley Medicare Solutions, call 716.849.8223.

 Question: I just went to the pharmacy to pick up my medications and my cost was over $550!! Last year I only paid $42 per month. What happened? I didn’t change my insurance!

Answer: During January and the beginning of February I hear this almost daily! I can probably tell you what is happening because it’s one of two situations. The first is that your plan has a deductible (up to $590) and you haven’t met that yet. The second is that your medication is no longer covered by your plan in 2025. I’ll explain both situations here.

First, let’s consider the deductible situation. When looking back to last January 2024, you may not remember what you paid the first time last year. Your prescription drug coverage may have had a deductible that you forgot about, your plan may have had a lower deductible, or it had no deductible at all.

Let me briefly explain your deductible. For your prescriptions, the deductible is like minimum amount you must spend before coverage “kicks in.” Before “meeting your deductible” (aka spending that minimum amount), you must pay full-price for your medications. Then once you meet that deductible (aka spend enough money on full-price medications), you move into your initial coverage phase. Then your insurance company will help pay for the cost of your medications, but you likely still pay a copay. The initial coverage phase usually structures their co-pays as tiers, where you may pay as low as $0 for certain drugs called Tier 1, then say $14 for Tier 2 drugs, and so on, usually up to Tier 5 or 6 at about $20-$30.

Most plans come with a deductible this year, so you probably have one. Also, the maximum allowable deductible this year is $590, and that is the most common deductible we’re seeing across plans this year. Medicare allows up to a $590 deductible, and in fact that is the most common deductible across plans this year. Some plans do have a deductible of just $450 or even $200 though.

The second reason your cost is over $550 could be because your medication isn’t covered by the plan you are in. It is my hope that you looked at the medications you take and you made sure that the plan you chose or decided to stay in from last year were still covered. Some people don’t evaluate that decision each year. They choose a product based on a recommendation of a friend, or an advertisement they see. We make assumptions that ALL medications are covered the same by ALL insurance. This is NOT the case. Each insurance product makes its own rules for coverage of all the medications available. Just because your insurance last year had your medication cost $42 per month, doesn’t mean that your plan has that same cost structure in the new year, or that it even covers your medications at all.

If you kept the same insurance product that you had last year, you may be running into this situation because insurance products change year-to-year. The plans change the deductible, the list of covered medications, the Tier that medications are assigned to, and their contracts with pharmacies. Note even if your plan did not change at all, your medications could have been different, and you paid the deductible at lower prices over several different purchases. All of these factors influence the amount you pay for your medications.

The first prescription fills of the year can be frustrating. Almost every person that comes to the counter has some question, or needs clarification on the cost. We may assume the pharmacy made a mistake. As a result, the Pharmacist explains that it isn’t their fault, it is your plan, because your insurance companies decide on the coverage rules and rates. The pharmacist will charge you for your medications according to your specific plan’s rates.

January through February is a tough time of year to be a Pharmacist – I would like to designate these months as “Hug Your Pharmacist” months. My tough time of year (October, November & December) has just ended. For the Pharmacist, and you, the frustration and questions have just started.

Be patient and ask questions. Also call your insurance company to give them your feedback on your co-pays. If they know you aren’t happy with this issue, maybe they will consider changing it for 2026. The more feedback they get, the better they will understand how we like their products. You also may have an opportunity to change your insurance now or later in the year even if you didn’t evaluate it during October-December. Give your insurance agent a call or use the Medicare.gov website to evaluate your options.

If you have questions or need assistance navigating your options, don’t hesitate to reach out to the Lawley Medicare Solutions Team. You can contact Medicare Service Team Lead Gabrielle Connor at 716.849.8223, or submit an inquiry through our contact form below. We’re here to help you find the right coverage for your needs!

At Lawley Medicare Solutions, our Medicare and Individual Health Consultants are dedicated to helping you make the most informed decisions about your healthcare needs. We offer personalized service and expert advice tailored to your unique situation. Contact us today by phone or email to schedule a consultation and ensure you’re getting the best coverage for your needs.

Read all Inside Medicare articles HERE.

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, call 716.849.8223.

 Question: I am turning 65 in April of 2025 and wondering about Medicare and Social Security Benefits. Should I be signing up now for Medicare and Social Security?

Answer: This is the second answer to this two-part question, so as I said last week, Happy Early Birthday!

Most of us understand you become eligible to file for Social Security Benefits when you are 62, and this age is considered early retirement. For those born in 1960 and after, Full Retirement Age (FRA) for Social Security Benefits is 67.

To collect Social Security, you must “file a claim” with the Social Security Administration (SSA). This contact with SSA can be via phone call, going to the local SSA office or using the www.ssa.gov website.

If you are comfortable with using the computer, the website might be a useful tool for you to use now and in the future. The SSA website allows you to create your own secure login at the www.SSa.gov/myaccount/ to access your own data. This login and password will enable you to return to this site any time you wish in the future, including when you file for Social Security benefits. Without a computer, you may contact SSA via their national number at 1-800-772-1213 or visit your local office.

Once you reach out to Social Security, you can learn what your actual benefits will be and when you can begin collecting those benefits.

As we said earlier, you are eligible to begin collecting Social Security at age 62 for early retirement benefits. This year you are turning 65, so still considered early retirement, but you could elect to collect your SS benefit anytime since turning 62.

How much you receive is based on your work history, using the best 35 years of earnings. As you are working throughout your life, your wages and taxes are put into the SSA System. This earnings record is then used to determine the amount you receive each month, once you file for Social Security Benefits. If you begin collecting Early Retirement Benefits (as early as age 62) you will receive less of a payment each month, but potentially more months of payments. If you wait until FRA at 67, you will collect the full amount based on your work history. If you do not collect until sometime after FRA, you will collect a higher monthly payment.

You can also continue to work AND collect SSA benefits. There are earning limits to be considered. If under FRA, as you are now, there is an earnings limit in 2025 of $23,400, which calculates to $1,950 per month. If you are working while collecting SSA early retirement benefits, and you earn more than $23,400, ($1950 monthly) your SSA benefits will be reduced by $1 for each $2 you earn above that amount. In the January of the year you reach FRA (for you is 2027), the earnings limit changes to $62,160, and your SSA benefits will be reduced by $1 for each $3 you earn. Once you reach FRA, you can work and collect SSA benefits with no limit on your earnings.

I advise individuals to use the SSA tools throughout their lives to determine their benefit amounts and when it is best to begin collecting Social Security. SSA staff are very good at explaining how YOUR numbers impact your filing for benefits decision. The website is also useful to track your numbers and how they can impact your decision on when it is best to collect Social Security Benefits.

If you are younger than 62, you can and should keep track of your situation with SSA. Be sure to check your work history against that of SSA, to ensure your wages were collected into their system and collected in the correct amounts. SSA will send you a report called “Your Social Security Statement” if you request this, or you can print it from the website. This report includes general information on Social Security and will include individual information on Your Estimated Benefits, Your Earnings Record and Social Security & Medicare Taxes paid by your and your employer.

You can go to the local SSA office closest to you or on the web at www.ssa.gov. I hope this information is helpful in helping you make that Social Security decision.

If you have questions or need assistance navigating your options, don’t hesitate to reach out to the Lawley Medicare Solutions Team. You can contact Medicare Service Team Lead Gabrielle Connor at 716.849.8223, or submit an inquiry through our contact form below. We’re here to help you find the right coverage for your needs!

At Lawley Medicare Solutions, our Medicare and Individual Health Consultants are dedicated to helping you make the most informed decisions about your healthcare needs. We offer personalized service and expert advice tailored to your unique situation. Contact us today by phone or email to schedule a consultation and ensure you’re getting the best coverage for your needs.

Read all Inside Medicare articles HERE.

LAWLEY HAS A TEAM DEDICATED TO MEDICARE INSURANCE!

Our licensed Medicare & Individual Health Insurance team can help clients understand the details of Medicare insurance plans, assist with choosing the right benefits and coverage, and provide guidance when life events that affect health coverage occur.

For questions, concerns, or to reach Lawley Medicare Solutions, call 716.849.8223.