Got Questions? We’ve Got Answers!
Medicare gives you two main paths for coverage — Original Medicare or Medicare Advantage — and understanding how they differ can help you make confident decisions about your health and budget.
Original Medicare (Parts A & B) is administered by the federal government. It allows you to see any doctor or hospital in the U.S. that accepts Medicare — no referrals or networks. You pay a monthly Part B premium, a hospital deductible, and generally 20% of medical services out-of-pocket. Many people add a Medicare Supplement (Medigap) plan and a Part D prescription plan to fill in the gaps and protect against larger bills.
Medicare Advantage (Part C) plans are offered by private insurance companies approved by Medicare. These plans combine Parts A and B and often include Part D drug coverage and extra benefits like dental, vision, hearing, and gym memberships. Advantage plans may have lower monthly premiums but use provider networks (HMOs or PPOs) that can limit which doctors you see.
In areas like Long Island and across the country, these plans can vary widely by county — so always compare networks, drug coverage, and out-of-pocket maximums before enrolling.
Need help deciding? schedule a free review with Paul Barrett at The Modern Medicare Agency (631-358-5793).
You can review and change your Medicare coverage during several key periods each year.
Annual Enrollment Period (AEP) — October 15 to December 7.
This is when you can switch from Original Medicare to Medicare Advantage (and vice versa), or change drug plans.
Open Enrollment Period (January 1 – March 31).
For those already in a Medicare Advantage plan, you can switch to another Advantage plan or return to Original Medicare.
Special Enrollment Periods (SEPs).
Life events such as moving to a new area, losing employer coverage, or qualifying for Extra Help allow plan changes outside normal windows.
If your plan stops working with your doctor — something that happens occasionally in New York networks like Northwell Health — you may also qualify for an SEP.
Pro tip: Always review your Annual Notice of Change (ANOC) letter each fall. It shows changes to premiums, copays, and drug coverage that could affect you in 2026.
A Medicare Supplement (Medigap) plan helps pay the costs that Original Medicare leaves behind — such as deductibles, coinsurance, and copays.
Original Medicare pays about 80% of approved medical services; you’re responsible for the other 20%. A Medigap plan steps in to cover most or all of that 20%, depending on the plan you choose.
For example:
Plan G covers nearly everything except the annual Part B deductible.
Plan N offers slightly lower premiums in exchange for small copays.
High-Deductible Plan G trades higher upfront costs for significantly lower monthly premiums.
Medigap plans don’t include prescription drug coverage (you’ll still need a Part D plan) and they don’t cover extras like dental or vision.
The biggest advantage? Freedom of choice. You can see any provider nationwide that accepts Medicare — no networks, no referrals. This makes Medigap ideal for snowbirds, travelers, or anyone who values flexibility.
In New York and many other states, you can switch Medigap plans year-round thanks to guaranteed-issue protections. If your premium has gone up, ask Paul Barrett about current rate comparisons to save money.
The Medicare Part D “donut hole” is the stage where you pay a higher share of your prescription drug costs after you and your plan reach a certain spending limit.
Here’s how it works in 2025:
You pay the deductible (up to $590 on most plans).
After that, you pay standard copays until total drug costs reach $2,000.
Starting January 2026, the $2,100 annual out-of-pocket cap will eliminate the donut hole as we know it. Once you reach $2,100 in true out-of-pocket costs (TrOOP), you’ll owe nothing for covered drugs for the rest of the year.
This historic change will help millions of Americans — including many of my Long Island clients with chronic conditions — save thousands on life-sustaining medications.
Read our full Medicare Part D Guide for 2026 to understand how this new law affects your coverage.
Beginning in 2025, the Inflation Reduction Act introduces a major reform: Medicare Part D plans must limit your annual out-of-pocket drug costs to $2,100.
Once your total out-of-pocket spending on covered prescriptions hits that threshold, you’ll pay $0 for the rest of the year. This replaces the previous “catastrophic phase,” where beneficiaries still paid 5% coinsurance.
This cap will:
Protect seniors from runaway pharmacy costs
Benefit high-utilization patients (such as those with diabetes or cancer)
Encourage carriers to redesign their Part D plans — expect to see new premiums, deductibles, and formularies in 2026
For New York consumers and beyond, this change is huge — many clients who once paid $5,000–$10,000 per year on specialty medications will now have predictable costs.
Tip: During the fall enrollment period, review your 2025 Part D plan carefully. Not all plans will price drugs the same way even with the new $2,100 cap. For personalized help, contact The Modern Medicare Agency (631-358-5793) or download our free Prescription Drug Checklist to compare plans effectively.
When comparing Medicare Advantage options, you’ll likely see two main types: HMO (Health Maintenance Organization) and PPO (Preferred Provider Organization). Both combine your Medicare Part A and B coverage — and often Part D prescription coverage — into a single plan offered by a private insurer, but they work very differently.
HMO plans generally require you to:
Choose a primary care doctor
Get referrals to see specialists
Use in-network providers only, except in emergencies
These plans typically have lower monthly premiums and out-of-pocket costs — but they offer less flexibility.
PPO plans let you see any doctor or specialist without a referral. You can go out-of-network, though you’ll usually pay more when you do. PPOs provide more freedom for people who travel or want access to specific hospitals or doctors.
Here in New York, many counties offer both options. Some PPOs include major health systems like Stony Brook or Northwell Health, while certain HMOs focus on smaller local networks.
Bottom line: HMO = lower cost, less freedom. PPO = more freedom, higher potential cost. Compare local HMO vs PPO plans or contact Paul Barrett for a personalized review.
Medigap premiums often rise over time — and understanding why helps you stay in control of your healthcare budget.
Insurance companies set Medigap rates using three main pricing methods:
Community-rated: Everyone pays the same premium regardless of age.
Issue-age-rated: Based on your age when you enroll; does not increase as you get older.
Attained-age-rated: Increases as you age — the most common method nationwide.
Other factors include medical inflation, carrier claims experience, and regulatory changes. For instance, in 2026, many New York carriers are implementing double-digit adjustments due to rising medical utilization.
The good news? You can shop around. In guaranteed-issue states like New York, you can switch Medigap plans anytime without health questions.
Tip: Review your supplement every year. A quick comparison can often save hundreds annually. Contact The Modern Medicare Agency for a complimentary Medigap rate check.
If your income is higher than average, you may pay more for Medicare Parts B and D through a surcharge called IRMAA — the Income-Related Monthly Adjustment Amount.
Each year, the Social Security Administration reviews your tax return from two years prior. If your modified adjusted gross income (MAGI) exceeds a certain threshold, you’ll pay an additional monthly amount on top of your standard Part B and D premiums.
For 2025, IRMAA starts when income exceeds roughly $106,000 for individuals or $212,000 for couples (subject to annual adjustment). The surcharge scales up in tiers.
You can request a reconsideration if your income has dropped due to a qualifying life event — such as retirement, divorce, or loss of income.
Many Long Island retirees experience IRMAA surprises after leaving the workforce. Proactive planning — often with your financial advisor — can help you manage your taxable income and minimize extra charges. Learn more in our Medicare Cost Planning Guide.
The Medicare Annual Enrollment Period (AEP) runs from October 15 to December 7 each year. It’s the one time most people can review and change their Medicare Advantage or Part D prescription coverage for the coming year.
During AEP you can:
Switch from Original Medicare to Medicare Advantage
Switch from one Advantage plan to another
Drop Advantage coverage and return to Original Medicare
Change or enroll in a Part D prescription plan
Any changes you make take effect on January 1 of the following year.
Because plans and networks often change — especially in dynamic markets like New York — reviewing your coverage each fall ensures your doctors, prescriptions, and costs still align with your needs.
Don’t wait until December! Review your Annual Notice of Change (ANOC) letter early and schedule a plan review with Paul Barrett or a local Modern Medicare Agency advisor for personalized guidance.
Keeping your trusted doctor is one of the most important factors when choosing Medicare coverage.
Here’s how to confirm that your physician is in-network:
Check the plan’s provider directory. Every Medicare Advantage carrier posts an online tool where you can search by name, specialty, or location.
Call your doctor’s office. Ask, “Do you participate in [Plan Name] Medicare Advantage network for next year?”
Work with an independent agent. Licensed brokers can verify participation across multiple carriers and warn you of recent contract changes.
In areas like Suffolk and Nassau County, some large hospital groups change contracts frequently — for instance, Mount Sinai’s exit from certain networks caused disruption for many seniors.
Tip: Always verify before enrolling. Provider networks can vary by ZIP code and even by plan ID number. Use our free Doctor & Prescription Checklist to ensure your preferred providers are covered before making changes.
Yes — you can switch from a Medicare Advantage plan (Part C) to a Medicare Supplement (Medigap) plan, but the timing and eligibility rules matter.
You can only enroll in a Medigap policy if you’re returning to Original Medicare (Parts A & B). The easiest time to do this is during the Annual Enrollment Period (Oct 15–Dec 7) or the Open Enrollment Period (Jan 1–Mar 31) for Advantage enrollees.
However, outside of guaranteed-issue states, insurance companies may ask health questions before approving your Medigap application. In New York, you’re protected by year-round guaranteed issue, so you can switch at any time without underwriting — a major advantage for Long Island residents.
Most people make this change because they want freedom to see any doctor nationwide or because their Advantage plan dropped key providers. If you switch, you’ll also need to add a Part D prescription plan, since Medigap policies don’t include drug coverage.
Pro tip: Don’t cancel your current plan until your new coverage is approved and active. Get step-by-step help at Modern Medicare Agency or call 631-358-5793.
When an insurance company stops offering your Medicare Advantage plan, Medicare calls it a “non-renewal” or “plan termination.”
If this happens, you’ll receive an official letter from your carrier — usually by October 2 — explaining that your plan will end on December 31. You’ll automatically have a Special Enrollment Period (SEP) that lets you:
Choose a new Medicare Advantage plan, or
Return to Original Medicare and purchase a Medigap plan plus Part D coverage.
Your SEP begins December 8 and lasts through the end of February following the termination.
In 2026, several carriers have announced plan exits in parts of New York, so this will affect many beneficiaries. If your carrier leaves the market, take action early — waiting until January can delay your new coverage.
Need help after a termination notice? The team at Modern Medicare Agency specializes in finding comparable plans and protecting your doctor access during transitions.
Comparing Medicare Part D plans is one of the smartest moves you can make each year — and it can save you hundreds of dollars.
Here’s how to do it:
List your medications. Include drug names, dosages, and preferred pharmacies.
Use the official Medicare.gov Plan Finder. Enter your drug list and ZIP code to view plans ranked by annual cost (premium + copays).
Review each plan’s formulary. Make sure your drugs are covered and check for any step-therapy or prior-authorization rules.
Compare pharmacy networks. Many plans offer preferred pricing at specific pharmacies — sometimes mail-order is cheaper.
Ask a licensed agent to double-check results; experienced brokers often catch small differences Medicare’s tool can miss.
In high-cost regions like New York, formularies and premiums can vary more than $600 per year between similar plans — so annual reviews matter.
Download Paul Barrett’s free Prescription Drug Checklist to make the process easy.
Yes, you can switch Medicare Supplement (Medigap) plans at any time — but the rules depend on your state.
In most states, switching requires medical underwriting, meaning the insurance company can ask health questions and potentially deny coverage. However, New York and a handful of other states are guaranteed-issue year-round, so you can change Medigap plans anytime without answering health questions.
People typically switch for three main reasons:
Premium savings: After several years, your current plan may have become overpriced compared to newer offerings.
Plan optimization: Moving from Plan F to Plan G or N can reduce premiums while keeping nearly identical coverage.
Carrier stability: Some carriers raise rates aggressively; others are known for long-term rate control.
The key is to compare all available options before switching. Even small monthly savings can add up to hundreds per year.
Tip: Don’t cancel your existing policy until your new one is approved and active. Contact The Modern Medicare Agency for a free Medigap rate comparison — no pressure, just education.
The year 2026 will bring some of the biggest Medicare updates in recent history.
Here’s what beneficiaries should expect:
Part D Out-of-Pocket Cap Adjustment: The new $2,000 cap takes full effect in 2025, but Part D premiums and formularies are expected to shift significantly in 2026.
Fewer plan choices: Carriers are consolidating and discontinuing underperforming Medicare Advantage and drug plans.
Rising Medigap premiums: Many states, including New York, are projecting double-digit rate increases due to inflation and guaranteed-issue enrollment pressure.
Network restructuring: Expect more HMO-style Advantage plans as insurers tighten networks to control costs.
Agent compensation changes: Some carriers are scaling back commissions, which may reduce available local support for consumers who enroll without a broker.
These shifts mean reviewing your coverage in late 2025 is essential — especially if you live in a competitive region like Long Island, where carrier networks and premiums fluctuate quickly.
Stay informed with our upcoming 2026 Medicare Guide — or subscribe at paulbinsurance.com to receive updates directly from Paul Barrett.
A Special Enrollment Period (SEP) allows you to make changes to your Medicare coverage outside of the usual Annual or Open Enrollment windows.
You may qualify for an SEP if:
You move to a new area where your current plan isn’t offered.
You lose employer or union coverage.
You gain or lose Medicaid or Extra Help (LIS) eligibility.
Your plan is terminated or violates CMS rules.
You experience a natural disaster or Medicare administrative error.
Each SEP has specific timing rules. For example, if you move, you typically have two months after your move to choose a new plan. If you lose employer coverage, your SEP lasts up to eight months.
Beginning in 2025, certain SEPs for dual-eligible (Medicare + Medicaid) or Extra Help beneficiaries will be limited to once per quarter rather than monthly — an important change designed to reduce confusion.
Tip: Always keep documentation of your qualifying event. If you’re unsure whether you qualify, Paul Barrett and his team can verify your eligibility in minutes.
Every fall, Medicare Advantage and Part D plan members receive an Annual Notice of Change (ANOC) — usually by September 30. This document outlines how your plan will change for the next year, including:
Premiums and deductibles
Copays and coinsurance
Prescription drug formulary changes
Network provider updates
Added or removed benefits
Reading this letter is one of the most important things you can do each year. Many beneficiaries ignore it and are surprised when their doctor leaves the network or their medications become more expensive.
On Long Island, for example, several major hospital systems have changed network status from year to year — impacting thousands of seniors who didn’t review their ANOC in time.
Pro tip: Compare your ANOC side-by-side with your doctors list and drug list. Need help reviewing? Download our free Medicare Plan Review Checklist or call The Modern Medicare Agency for a personalized analysis.
The Annual Enrollment Period (AEP) runs from October 15 to December 7, and preparation is key to avoiding costly mistakes.
Here’s how to get ready:
Review your ANOC letter. Note any changes in premiums, copays, or provider networks.
Update your doctor and prescription list. Coverage can change, so have accurate details ready.
Check your preferred pharmacies. Drug pricing can vary widely by location.
Compare your plan with new options. Even if you like your plan, newer versions may save you money.
Schedule your annual review early. Don’t wait until December when phone lines are busiest.
Each year, thousands of Medicare beneficiaries overpay or lose coverage simply because they didn’t review their plan.
Original Medicare (Parts A & B) does not cover most routine dental, vision, or hearing care — and that surprises many new enrollees.
Here’s the breakdown:
Dental: Cleanings, fillings, dentures, and implants aren’t covered. Medicare only covers dental procedures directly tied to a covered medical service (for example, jaw reconstruction after an injury).
Vision: Eye exams for glasses or contacts aren’t covered, but Medicare Part B covers annual eye exams for diabetic retinopathy and glaucoma screenings if you’re at risk.
Hearing: Routine exams and hearing aids are not covered, although diagnostic tests ordered by a doctor may be.
If you want these benefits, you have three main options:
Choose a Medicare Advantage plan that includes dental, vision, and hearing. Many carriers now offer generous benefit packages, though coverage limits vary.
Buy standalone dental or vision insurance — especially if you have high-cost dental needs.
Use a dental discount plan or membership savings network.
In New York, many Advantage plans include these extras, but always read the fine print. A $2,000 “dental benefit” may sound generous but could be capped per service type.
Tip: Always compare how much coverage you’ll actually use vs. paying out-of-pocket. Explore your options in our Medicare Dental, Vision & Hearing Guide.
If your doctor leaves your Medicare Advantage plan’s network mid-year, it can be stressful — but you have options.
When a provider leaves a network, your plan must notify you in writing. If your doctor’s departure makes it difficult to receive needed care, you may qualify for a Special Enrollment Period (SEP) to switch plans or return to Original Medicare.
Here’s what to do:
Call your plan immediately to confirm the change and discuss in-network alternatives.
Ask your doctor’s office if they’ve joined another network or are open to seeing you as a self-pay patient temporarily.
Contact an independent agent like Paul Barrett — they can quickly check which plans still include your providers and help you make a seamless transition.
For example, when Mount Sinai dropped out of several Medicare Advantage networks in New York, many patients were unaware until January. Staying proactive ensures you never face surprise bills or coverage gaps.
Pro tip: Always confirm your doctors’ network participation during AEP each fall. Use our free Doctor & Prescription Checklist to stay ahead of changes.
Medicare scams and misleading marketing are at an all-time high — especially during the fall enrollment season.
Here’s how to protect yourself:
Be wary of unsolicited calls or texts. Medicare will never call you to sell a plan.
Avoid giving your Medicare number to anyone who contacts you first.
Beware of “too good to be true” ads. Some commercials exaggerate benefits or misrepresent specific ZIP code eligibility.
Confirm the source. Only trust information from licensed agents, Medicare.gov, or official insurance carriers.
Hang up on “free money” offers. Pitches about “rebates in your Social Security check” are often misleading or incomplete.
As a licensed independent agent, Paul Barrett is required to follow strict CMS marketing guidelines — meaning you’ll always receive transparent, fact-based information.
If you suspect fraud, call 1-800-MEDICARE or report it to your local Senior Medicare Patrol. Read our blog post: “Is Anyone Telling You the Truth About Medicare?” — a must-read for 2026 AEP.
IRMAA (Income-Related Monthly Adjustment Amount) is a surcharge applied to Medicare Part B and Part D premiums for higher-income individuals.
It’s based on your Modified Adjusted Gross Income (MAGI) from two years prior. For example, your 2025 IRMAA is determined by your 2023 tax return. The more income you report, the higher your monthly premiums.
You can’t avoid IRMAA entirely if your income is above the threshold, but you can plan strategically to reduce it:
Delay large Roth conversions or stock sales until after your IRMAA calculation year.
Manage Required Minimum Distributions (RMDs) with a tax advisor.
Use Qualified Charitable Distributions (QCDs) from IRAs to lower taxable income.
File an IRMAA appeal (Form SSA-44) if your income has dropped due to life changes like retirement, divorce, or death of a spouse.
For Long Island retirees — especially those transitioning from high-paying careers — IRMAA surprises are common. Smart tax planning can prevent overpaying thousands of dollars each year.
Tip: Coordinate with your financial advisor or call The Modern Medicare Agency to learn how to align your Medicare and tax strategy.
Working with an independent, local Medicare agent gives you an advantage that 1-800 numbers and call centers can’t match: personalized, unbiased guidance.
Here’s what sets agents like Paul Barrett apart:
Access to multiple carriers. Independent brokers compare plans from all major companies — not just one.
Unbiased recommendations. Your needs come first; agents don’t work for any insurance company.
Ongoing support. If your doctor leaves a network or a bill looks wrong, your agent helps fix it — no hold music.
Local insight. A Long Island-based broker understands which plans include networks like Northwell or Stony Brook, and which carriers historically perform best in Suffolk and Nassau Counties.
No extra cost. Agents are paid by insurance carriers — your premium is the same whether you use an agent or not.
Bottom line: You could spend hours researching plans — or get clear answers in minutes. Schedule your free consultation today at paulbinsurance.com or call 631-358-5793.
