FAQ
Medicare Frequently Asked Questions
Medicare can feel overwhelming. Between Medicare Parts A, B, C and D, Medicare Advantage, Medicare Supplements, prescription coverage, Medicaid, Extra Help, “food cards,” chronic-condition plans and enrollment periods, it is easy to understand why people have questions.
At Gilliam Insurance Advisor Group, our goal is not simply to help you enroll in insurance. Our goal is to help you understand what you have, what you may qualify for, and what choices are available to you before you make a decision.
We help Medicare beneficiaries throughout East Tennessee and Southwest Virginia, including Kingsport, Johnson City, Bristol and surrounding communities.
GETTING STARTED WITH MEDICARE
What is Medicare?
Medicare is federal health insurance primarily for people age 65 and older. Certain people under 65 may also qualify because of a disability, End-Stage Renal Disease (ESRD), or ALS.
What are the different parts of Medicare?
Medicare Part A helps cover inpatient hospital care, skilled nursing facility care under qualifying circumstances, hospice and certain home health services.
Medicare Part B helps cover doctor visits, outpatient care, preventive services, diagnostic testing, durable medical equipment and many other medically necessary services.
Medicare Part C, also called Medicare Advantage, is an alternative way to receive your Medicare Part A and Part B benefits through a private insurance company approved by Medicare. Most Medicare Advantage plans also include Part D prescription drug coverage and may include additional benefits.
Medicare Part D helps pay for covered prescription medications.
When should I start preparing for Medicare?
Ideally, start learning about your options several months before turning 65. Waiting until the last minute can create unnecessary stress and, depending on your circumstances, could lead to enrollment delays or penalties.
Do I automatically get Medicare when I turn 65?
Not always. Some people receiving Social Security or Railroad Retirement benefits are automatically enrolled in Medicare. Others need to actively enroll. Whether you should enroll in Medicare at 65 can also depend on whether you or your spouse are still working and what type of employer health coverage you have.
I’m still working at 65. Do I have to take Medicare?
Not necessarily. The answer depends on who carries the employer coverage, employer size, whether coverage is based on current employment, whether you contribute to an HSA, what the employer plan costs, and whether Medicare may be more economical. This is an area where getting advice before making a change is extremely important.
What if my spouse is still working and I am covered under their insurance?
You may be able to delay some parts of Medicare without penalty if the coverage qualifies. However, employer size and the type of coverage matter. Have the situation reviewed before making that decision.
What if I have COBRA when I turn 65?
COBRA and active employer coverage are not treated the same way by Medicare. In many situations, COBRA does not protect you from Medicare late-enrollment penalties or missed enrollment deadlines. If you have Medicare or are approaching 65 and considering COBRA, talk with someone knowledgeable about Medicare before making your decision.
MEDICARE COSTS
Is Medicare free?
No. Many people receive premium-free Part A because they or their spouse paid Medicare taxes long enough while working. Most people pay a monthly premium for Part B. Depending on the coverage you choose, you could also have premiums, deductibles, copayments and coinsurance.
Does Original Medicare pay 100% of my medical bills?
No. Original Medicare generally leaves deductibles and cost sharing for the beneficiary. For many Part B services, after the applicable deductible is met, Medicare generally pays 80% of the Medicare-approved amount and the beneficiary is responsible for approximately 20%.
Is there a maximum out-of-pocket limit with Original Medicare?
Original Medicare by itself does not have the same annual maximum out-of-pocket protection that Medicare Advantage plans have for covered Part A and Part B services.
What is the Medicare Part B deductible?
The Part B deductible is an amount you generally pay toward covered Part B services before Medicare begins paying its share. The amount can change each year.
MEDICARE ADVANTAGE
What is a Medicare Advantage plan?
Medicare Advantage, also called Medicare Part C, is another way to receive your Medicare Part A and Part B benefits. Medicare Advantage plans are offered by private insurance companies approved by Medicare. Plans must cover the services Original Medicare covers, but costs, provider networks, drug coverage and additional benefits vary by plan.
Do I lose Medicare if I choose Medicare Advantage?
No. You are still enrolled in Medicare and must continue to meet Medicare eligibility requirements. You are simply choosing to receive your Medicare-covered benefits through a Medicare Advantage plan instead of receiving them directly through Original Medicare.
Are Medicare Advantage plans really $0?
Some Medicare Advantage plans have a $0 monthly plan premium, but that does not mean healthcare is completely free. You may still have your Medicare Part B premium, copayments, coinsurance, deductibles, prescription costs and out-of-network costs where applicable.
What is the difference between an HMO and PPO?
An HMO generally uses a defined provider network. Except for emergencies and certain other situations, receiving services outside the network may not be covered.
A PPO generally gives you more flexibility to use providers outside the plan’s network, although you may pay more.
Neither type is automatically better. The right choice depends on your doctors, hospitals, travel habits, medications, budget and healthcare needs.
Can I keep my doctor if I enroll in Medicare Advantage?
Possibly, but you should never assume your doctor participates. Provider networks can differ from one plan to another, even between plans offered by the same insurance company. We recommend verifying your important doctors, specialists and hospitals before enrollment.
What if my doctor says they take Medicare?
That does not necessarily mean they participate with every Medicare Advantage plan. Original Medicare and Medicare Advantage are different. Always verify the specific plan and network.
Can my doctor leave my Medicare Advantage network?
Yes. Provider networks can change. This is one reason Medicare coverage should be reviewed periodically.
Does Medicare Advantage cover me while traveling?
Emergency and urgently needed services have protections, but routine care rules can vary according to the type of plan. People who travel frequently or spend significant time in another state should make travel needs part of their Medicare decision.
Do Medicare Advantage plans include dental, vision and hearing?
Many plans offer additional benefits such as dental, vision or hearing coverage. However, benefits differ considerably by plan. Ask exactly what is covered, whether there is an annual allowance or network, whether dentures or implants are covered, whether prior authorization is required, and whether frequency limits apply.
MEDICARE SUPPLEMENT / MEDIGAP
What is a Medicare Supplement?
A Medicare Supplement policy, also called Medigap, works with Original Medicare to help pay certain costs Original Medicare leaves behind. Medigap is different from Medicare Advantage.
Can I have Medicare Advantage and a Medicare Supplement at the same time?
No. They are different ways of structuring your Medicare coverage. A Medicare Supplement works alongside Original Medicare. A Medicare Advantage plan provides your Medicare Part A and Part B benefits through the plan.
Does a Medicare Supplement include prescription coverage?
Modern Medicare Supplement policies generally do not include prescription drug coverage. Someone with Original Medicare and a Medicare Supplement will often also consider a separate Medicare Part D prescription drug plan.
Can I change Medicare Supplement companies whenever I want?
You can apply, but outside certain protected enrollment periods, the insurance company may be allowed to ask health questions or use medical underwriting depending on applicable law and circumstances. Do not cancel an existing Medicare Supplement until you know your new coverage is approved and understand its effective date.
What is the best Medicare Supplement company?
There is no single company that is best for everyone. Medicare Supplement plans with the same letter generally provide standardized basic benefits, but companies can differ in premium, rate history, household discounts, underwriting, customer service and financial strength.
PRESCRIPTION DRUG COVERAGE
Do I need Medicare Part D if I don’t take prescriptions?
Possibly. Going without creditable prescription drug coverage can result in a Part D late-enrollment penalty if you later enroll. The fact that you take no medications today does not mean you will never need drug coverage.
Why is my medication inexpensive on one Medicare plan and expensive on another?
Every Medicare drug plan has its own formulary, cost-sharing structure and participating pharmacy arrangements. The exact same medication can therefore cost very different amounts from one plan to another.
Should my prescriptions be checked every year?
Yes. Prescription formularies, pharmacy relationships and plan costs can change. A plan that worked well this year may not necessarily be the best fit next year.
Why does my pharmacy matter?
Some plans have preferred pharmacies where certain medications may cost less. Changing pharmacies can sometimes make a significant difference in annual prescription costs.
What if one of my prescriptions isn’t covered?
Depending on the circumstances, options may include asking whether an alternative covered medication is appropriate, requesting a formulary exception, reviewing prior authorization requirements, or reviewing other plan options during an eligible enrollment period. Never stop or change a prescribed medication without discussing it with your healthcare provider.
EXTRA HELP WITH PRESCRIPTIONS
What is Medicare Extra Help?
Extra Help, also known as the Low-Income Subsidy or LIS, is a federal program that helps qualifying Medicare beneficiaries with Medicare Part D prescription drug costs. It can reduce costs such as premiums, deductibles and prescription copayments.
How do I qualify for Extra Help?
Eligibility is based on income, resources and other circumstances. Some people automatically receive Extra Help because they have Medicaid or qualify for certain Medicare Savings Programs. Others can apply through Social Security.
Do I have to be on Medicaid to receive Extra Help?
No. Some people qualify for Extra Help even though they do not have full Medicaid. This is one of the most common misconceptions we hear.
MEDICARE SAVINGS PROGRAMS
What is a Medicare Savings Program?
Medicare Savings Programs are administered through Medicaid and can help qualifying Medicare beneficiaries pay certain Medicare costs. Categories include QMB, SLMB, QI and QDWI. The assistance available depends on the category for which you qualify.
What is QMB?
QMB stands for Qualified Medicare Beneficiary. For qualifying individuals, QMB can help pay Medicare Part A premiums when applicable, Part B premiums, deductibles, coinsurance and copayments for Medicare-covered services. People with QMB also automatically qualify for Extra Help with Medicare prescription drug costs.
What are the 2026 QMB income guidelines?
For 2026, the general federal QMB monthly income limits are approximately $1,350 for an individual and $1,824 for a married couple. Resource limits and state-specific rules also apply. States may use different rules when determining eligibility, and certain income may not be counted. Someone slightly above a published figure should not automatically assume they are ineligible.
What is QMB Plus?
“QMB Plus” generally refers to someone who qualifies for the QMB Medicare Savings Program and also receives full Medicaid benefits. Eligibility for full Medicaid is determined by the state, so income, resource and other requirements can vary.
What is SLMB?
SLMB stands for Specified Low-Income Medicare Beneficiary. For qualifying individuals, it generally helps pay the Medicare Part B premium. People who qualify for SLMB also receive Extra Help with prescription drug costs.
What is QI?
QI stands for Qualifying Individual. For qualifying beneficiaries, it generally helps pay the Medicare Part B premium. People who qualify for QI also receive Extra Help with prescription drug costs. QI benefits are subject to program requirements and generally require reapplication each year.
I’m just over the income limit. Should I still apply?
Possibly, yes. States may have different eligibility rules and may not count certain income or resources. Don’t disqualify yourself based on a quick internet search.
“FOOD CARDS” AND FLEX CARDS
What about the “food card” I keep hearing everyone talk about?
Advertisements sometimes call these benefits a food card, grocery card, flex card, healthy-food benefit or spending allowance. There is not one universal Medicare food card that everyone on Medicare receives.
Certain Medicare Advantage plans may offer qualifying members supplemental benefits that can include approved healthy foods, over-the-counter products, utilities or other eligible expenses. Eligibility varies by the specific plan and benefit.
Some benefits may be available to people who have both Medicare and Medicaid. Others may be available to qualifying members with certain chronic health conditions. The qualifying rules, allowed purchases and dollar amount can all differ. Having Medicare alone does not automatically qualify someone for a grocery benefit.
Do I have to have Medicare and Medicaid to get a food or grocery benefit?
Not always. Some benefits are associated with Dual Eligible Special Needs Plans for people who have both Medicare and Medicaid, while certain supplemental benefits may be offered to qualifying members with chronic conditions. The rules vary by plan.
What chronic conditions may qualify someone for special Medicare plans or benefits?
Depending on plans available in your area, qualifying conditions may include diabetes, certain cardiovascular conditions, chronic heart failure, chronic lung disorders and other Medicare-approved chronic conditions. Plan availability and qualification requirements vary.
Is the food card the same amount on every plan?
No. Benefits can differ significantly. One plan may offer a particular benefit while another offers none. Eligible items, amounts, frequencies and qualification requirements can also differ.
Should I switch Medicare plans just to get a food card?
Usually, that should not be the first question. Before switching plans, evaluate your doctors, specialists, hospitals, prescriptions, expected medical costs, maximum out-of-pocket exposure, pharmacy, travel needs and prior authorization requirements. Then look at additional benefits.
MEDICARE & MEDICAID
Can I have Medicare and Medicaid at the same time?
Yes. People who qualify for both are often referred to as dual eligible. Medicare generally pays first for Medicare-covered services, with Medicaid acting as secondary coverage according to applicable Medicaid rules.
What is a D-SNP?
D-SNP stands for Dual Eligible Special Needs Plan. It is a type of Medicare Advantage Special Needs Plan designed for people who have both Medicare and qualifying Medicaid coverage. These plans may help coordinate Medicare and Medicaid benefits and may include additional benefits depending on the plan.
Are all people with Medicaid eligible for the same D-SNP benefits?
No. Medicaid eligibility categories matter, and plans may have specific eligibility requirements. That is why we verify the person’s Medicare and Medicaid status before recommending a plan.
What happens if I lose Medicaid?
Don’t ignore the notice. Losing Medicaid can affect your healthcare costs, Medicare plan eligibility, extra benefits, prescription costs and special enrollment rights. Contact us as soon as you learn your Medicaid status is changing so your options can be reviewed.
CHRONIC CONDITION SPECIAL NEEDS PLANS
What is a C-SNP?
A Chronic Condition Special Needs Plan, or C-SNP, is a Medicare Advantage plan specifically designed for people who meet the plan’s requirements for certain severe or disabling chronic conditions.
I have diabetes. Are there special Medicare plans for me?
Possibly. Depending on where you live and plans available in your county, there may be Chronic Condition Special Needs Plans designed for qualifying Medicare beneficiaries with diabetes. Eligibility must be verified.
I have heart disease. Could I qualify for a Chronic Special Needs Plan?
Possibly. Certain cardiovascular conditions may qualify for specific C-SNPs, depending on the plan’s eligibility criteria. The exact diagnosis matters.
I have COPD. Are there special Medicare plans available?
Certain chronic lung disorders may qualify for C-SNP coverage where those plans are available. The exact plan requirements and diagnosis must be verified.
Does having a chronic condition automatically qualify me for extra money?
No. Having a qualifying chronic condition may make someone eligible for a particular plan or certain supplemental benefits, but it does not mean Medicare automatically sends everyone with that condition money.
ENROLLMENT PERIODS
When can I change my Medicare plan?
That depends on your circumstances. Common enrollment opportunities include the Annual Enrollment Period, Medicare Advantage Open Enrollment Period, Initial Enrollment Period and Special Enrollment Periods. The fact that it is not Annual Enrollment Period does not necessarily mean you have to wait until fall.
What is the Medicare Annual Enrollment Period?
The Annual Enrollment Period is generally October 15 through December 7 each year. During this period, eligible Medicare beneficiaries can make certain changes to Medicare Advantage and prescription drug coverage for the following year.
What is Medicare Advantage Open Enrollment?
The Medicare Advantage Open Enrollment Period generally runs January 1 through March 31. It applies to people already enrolled in a Medicare Advantage plan and allows certain plan changes.
Can I change Medicare plans outside AEP?
Possibly. Special Enrollment Periods can arise from circumstances such as moving, losing certain coverage, gaining or losing Medicaid, qualifying for Extra Help, certain changes involving institutional care, or other Medicare-recognized situations.
I moved. Can I change Medicare plans?
A permanent move may create a Special Enrollment Period, particularly if you move outside your plan’s service area or new plan options become available. Call before or soon after moving so important deadlines are not missed.
I recently qualified for Medicaid or Extra Help. Can I change plans?
You may have additional enrollment opportunities. The exact options and timing depend on your eligibility and current coverage.
CHOOSING A PLAN
What is the best Medicare plan?
There is no Medicare plan that is best for everyone. The best plan for you depends on your doctors, prescriptions, preferred hospitals, medical conditions, budget, travel habits, pharmacy, tolerance for copayments, preference for Original Medicare versus managed care, and benefits available where you live.
Should I choose a plan based on the dental benefit?
Not by itself. Dental benefits can be valuable, but your medical coverage should remain the priority. We evaluate the entire plan rather than chasing one attractive benefit.
Should I choose the plan with the largest flex card?
Not necessarily. A large advertised allowance can get attention, but first determine whether you actually qualify for it. Then evaluate the rest of the plan.
Why can’t my neighbor just tell me which Medicare plan to get?
Because your neighbor may have different doctors, medications, health conditions, Medicaid status, financial eligibility and priorities. The plan that is excellent for your neighbor could be a poor fit for you.
My doctor recommended an insurance company. Should I just choose it?
A doctor’s office may know which plans it accepts, but it generally does not have all the information needed to compare your medications, benefits, costs and other plan choices. Provider participation is important, but it is only one part of the decision.
ANNUAL MEDICARE REVIEW
Do I have to change Medicare plans every year?
No. You should not change simply for the sake of changing. But you should review your coverage because premiums, copays, provider networks, drug formularies, pharmacy pricing, additional benefits and maximum out-of-pocket limits can change. Sometimes the best decision is to stay exactly where you are.
If I like my plan, why should I review it?
Because liking the plan this year does not guarantee that its costs and benefits will remain identical next year. A yearly review can catch changes before they surprise you.
SCAMS AND MISLEADING MEDICARE ADVERTISING
Medicare keeps calling me. Is that really Medicare?
Be cautious. Scammers may impersonate Medicare, insurance companies, government agencies or healthcare organizations. Never give your Medicare number, Social Security number, banking information or other sensitive information to an unexpected caller unless you have verified who they are.
Someone called and said Medicare is sending me a new plastic card. Is that legitimate?
Medicare scams frequently involve claims about new cards, replacement cards, benefits or expiring coverage. If you are uncertain, do not provide personal information. Hang up and contact Medicare or a trusted local advisor through a phone number you independently know is legitimate.
Should I give someone my Medicare number just to get a quote?
Protect your Medicare information. A Medicare number can be used for purposes beyond simply discussing general plan information. Understand why the information is being requested and who you are providing it to.
Are those television commercials about extra Medicare benefits real?
Some advertised benefits are real benefits offered by certain Medicare Advantage plans. However, not everyone qualifies, benefits are not available everywhere, and advertisements may emphasize attractive extras without explaining the full healthcare coverage.
What should I do if someone pressures me to change plans?
You do not have to make an immediate decision because someone calls, knocks on your door or tells you a benefit is “ending today.” Slow down, ask questions, verify your doctors and prescriptions, and understand what you are leaving before enrolling somewhere new.
WORKING WITH AN INDEPENDENT MEDICARE AGENT
Why work with an independent Medicare agent?
An independent agent may represent multiple insurance companies rather than only one carrier. That allows the conversation to start with your needs rather than with only one company’s product.
Does it cost more to use an agent?
Generally, you do not pay an additional premium simply because a licensed agent helped you enroll in a Medicare plan. Agents may be compensated by insurance companies when permitted.
Why use a local agent instead of a national call center?
Having a local agent gives many clients something especially valuable: a person they know how to find after enrollment. We understand many of the physicians, hospitals, pharmacies and community resources used by people in East Tennessee and Southwest Virginia.
Can you help me after I enroll?
Yes. We believe service after enrollment matters. Depending on the situation, our office may help clients understand plan information, identify whom to contact, review coverage changes and prepare for future Medicare decisions.
Will you tell me if staying in my current plan is the best option?
Yes. A Medicare review does not always need to end with a plan change. Sometimes the best advice is: “Your current plan still fits you well. Stay where you are.”
QUESTIONS PEOPLE ARE SOMETIMES AFRAID TO ASK
I don’t understand Medicare at all. Is that unusual?
Absolutely not. Most people spend decades receiving health insurance through an employer and are suddenly expected to understand Medicare terminology, enrollment periods, formularies, provider networks, drug tiers and multiple coverage options.
I already enrolled in something I don’t understand. Can you still help me?
Yes. Bring what you have. We can start by helping you understand your current coverage and then determine what options, if any, are available.
I don’t use computers very well. Can I still get help?
Yes. You should not have to be technologically savvy to understand your health insurance.
I’m embarrassed that I don’t understand my insurance. Should I be?
No. Insurance language is complicated. Ask every question you have, even the ones you think you should already know.
My income is limited. Is it worth talking with someone?
Absolutely. There are programs many Medicare beneficiaries never realize they may qualify for, including Extra Help with prescription costs, Medicare Savings Programs, Medicaid, Special Needs Plans and other state or community assistance programs.
BEFORE YOU CHANGE YOUR MEDICARE COVERAGE
What should be checked before I change plans?
Before enrolling in a new Medicare plan, make sure someone has checked your primary care physician, specialists, preferred hospitals, every prescription, pharmacy, chronic medical conditions, Medicaid status, Extra Help status, expected medical costs, maximum out-of-pocket exposure, dental, vision, hearing, transportation where available, over-the-counter benefits where available, grocery or healthy-food benefits if applicable, travel needs, network, referrals and prior authorization considerations.
A Medicare plan should fit your healthcare, not the other way around.
TURNING 65?
How can Gilliam Insurance Advisor Group help if I am turning 65?
We can help you understand when you should enroll, whether you can delay Medicare, Part A and Part B, Medicare Advantage, Medicare Supplements, Part D prescription coverage, employer coverage, COBRA considerations, prescription costs, your doctors and hospitals, and programs that may help reduce Medicare costs.
The best time to understand Medicare is before you have to make the decision.
ALREADY ON MEDICARE?
Why should I review my coverage if I’m already enrolled?
Your needs can change. Your health can change. Your prescriptions can change. And Medicare plans can change. A review may confirm that your current plan is still exactly where you should be, or that another option deserves consideration.
MEDICARE HELP IN EAST TENNESSEE & SOUTHWEST VIRGINIA
What makes your approach different?
Gilliam Insurance Advisor Group helps people throughout our region understand Medicare in plain English. We believe you deserve more than someone reading benefits from a computer screen. You deserve someone who will listen first, ask questions, check the details, explain your choices and still be here after enrollment.
Have a Medicare question that isn’t listed here?
Ask us. Chances are, if you’re wondering about it, someone else is too. And there is no such thing as a silly Medicare question.
Important Medicare Disclaimer
We do not offer every plan available in your area. Please contact Medicare.gov, 1-800-MEDICARE, or your local State Health Insurance Program (SHIP) to get information on all of your options.
Plan availability, benefits, eligibility requirements, provider networks, prescription formularies, premiums, copayments and supplemental benefits vary by plan, service area and year.
Eligibility for Medicaid, Extra Help and Medicare Savings Programs is determined by the appropriate government agency and is subject to applicable income, resource and program requirements.
This website is intended for educational purposes and is not affiliated with or endorsed by the U.S. government or the federal Medicare program.
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