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1. Medicare Enrollment is More Than Picking a Plan

Many clients believe Medicare enrollment is simply choosing a plan from carriers like UnitedHealthcare, Humana, or Aetna. In reality, enrollment involves six steps:

1. Timing – Deciding when to enroll (age 65 vs. delaying due to employer coverage, HSAs, etc.).
2. Path – Choosing between Original Medicare or Medicare Advantage.
3. Plans – Selecting specific carriers and products.
4. Enrollment – Completing Part A/B enrollment via Social Security.
5. Adding Coverage – Adding Part D or Medigap.
6. Annual Review – Reviewing coverage every year.

📖 Reference: Medicare.gov – Getting Started

2. Original Medicare vs. Medicare Advantage

Original Medicare (A + B + Medigap + Part D):

• National access (Mayo, Cleveland Clinic, etc.).
• Few prior authorizations.
• Predictable costs with Medigap.
• Medigap = “cost insurance,” not health insurance, covering out-of-pocket gaps.

Medicare Advantage (Part C):

• Private insurance companies manage care.
• Attractive features: $0 premiums, bundled drug coverage, extras (dental, vision, gym).
• Risks: narrow networks, high prior authorization rates (50M vs. <400K in Original Medicare, 2023), and higher cost exposure ($4,700–$9,000+ out-of-pocket caps).

📖 Reference: KFF – Medicare Advantage Facts

3. Medigap Policy Considerations

• Plans are standardized (e.g., Plan G, N, F). Benefits are identical across carriers; only cost structure differs.
• Plan G is generally best (“greatest”), with N as a secondary option. Plan F is closed to new enrollees and shrinking in value.
• Premium increases depend on:
  • Risk pool size/health.
  • Medical loss ratios (MLR): ideal range 60–80%.
  • Pricing model: attained age (rises annually with age), issue age (locked at enrollment age), or community rated (flat, but may use disguised increases).

📖 Reference: Medicare.gov – Medigap Policy Choices

4. Part D Drug Plans – What Really Matters

• Coverage is private, not federal. Formularies vary; not all drugs covered.
• “Preferred” pharmacies may cost more than standard—always compare.
• Average premium in 2025 ≈ $46. Plans cluster into low ($0–15) or high ($80+).
• Out-of-pocket cap = $2,000 in 2025 (per Inflation Reduction Act), but only applies if all prescriptions are covered by the plan.
• Compare based on the three-legged stool: coverage, cost, and quality (star ratings, prior auths, pharmacy access).

📖 Reference: Medicare.gov – Drug Coverage (Part D)

5. Using Tools: Medicare.gov vs. Hey Mo

• Medicare.gov Plan Finder is essential but cumbersome: requires repeated manual entry, doesn’t store drugs without a Medicare account, and hides prior authorization info.
• Hey Mo ($30/year) automates re-checking during open enrollment, tests brand/generic swaps, compares across 20 pharmacies, and flags prior authorizations and GoodRx coupons.

📖 Reference: Medicare.gov – Plan Finder

6. IRMAA (Income-Related Monthly Adjustment Amount)

• Applies when MAGI exceeds $106,000 (single) or $212,000 (joint) in 2025.
• Advisors should plan for IRMAA tiers in retirement income planning.
• SSA-44 form allows clients to appeal IRMAA after life-changing events (e.g., retirement, work reduction).

📖 Reference: SSA – Medicare IRMAA Appeals

7. Advisor Red Flags & Guidance

• Clients delaying Medicare without creditable coverage risk permanent penalties.
• Medicare Advantage often marketed heavily by agents due to 40% higher commissions vs. Medigap; advisors should encourage clients to ask probing questions.
• Encourage annual Part D reviews—only ~30% of beneficiaries do, yet savings can be thousands (recorded case: $149,000 saved by switching).
• Retiree health coverage varies widely—must be compared individually against Medigap or Advantage.

📖 Reference: NCOA – Medicare Mistakes

✅ Bottom Line for Financial Advisors:

• Focus client discussions on timing, path, and annual reviews, not just plan selection.
• Integrate Medicare costs and IRMAA into broader retirement income and tax planning.
• Be aware of agent incentives that may bias recommendations toward Advantage.
• Use tools (Medicare.gov, Hey Mo, or CSG data) to validate plan costs, networks, and quality—not just premiums.