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Hi Toni:

I never should have listened to my brother, who bragged about how his Medicare Advantage Plan was a great way to save money and not have to spend so much on my Medicare supplement plan’s premium. I discovered that the eye doctor who was to perform surgery on my right eye in early January is not in my Medicare HMO plan. I should have called his office before I signed up for it.

Now my eye surgery is postponed since the doctor’s office is requesting that I return to Original Medicare to do the type of surgery that is needed. Can you explain how and when I can return to Original Medicare? I am glad I did not cancel my Medicare Supplement Plan G even though the premium has increased. Thanks, Toni.

–Stephanie from Denver, Colo.

Hello, Stephanie:

Readers, if you have discovered you made the wrong choice in selecting a Medicare Advantage (MA) Plan during Medicare’s Open Enrollment Period (OEP), which ended on December 7, I have good news for you. Beginning January1, you can return to Original Medicare or change to a different Medicare Advantage Plan during the Medicare Advantage Open Enrollment Period (MA OEP).

During MA OEP, a person can switch from one Medicare Advantage Plan to another Medicare Advantage Plan, or to Original Medicare with or without Part D and a Medicare Supplement plan. Only individuals on a Medicare Advantage Plan can utilize the Medicare Advantage Open Enrollment Period (MA OEP). The enrollment time is from January 1 through March 31 each year. This information is provided on page 72 of the 2026 Medicare & You handbook.

Changes in your chosen Medicare coverage start the first day of the month after the specific plan receives the change. Enrolling in MA OEP in January change begins February 1,enrolling in February change begins March 1,enrolling in March change begins April 1. After March 31, MA OEP ends and one is “locked” into whatever Medicare Advantage or Medicare Part D prescription drug plan you’ve chosen.

From April 1 to December 31, one is “locked”  and must wait until the next Medicare Annual Enrollment Period (AEP), which occurs annually from October 15 through December 7. During this period one can change to a different plan or return to Original Medicare with the specific Medicare change that will begin January 1of the next year.

Stephanie, you made a smart choice with not cancelling your Medicare Supplement due to your health issues because you may not be able to qualify for a new Medicare Supplement plan. Most Americans do not realize that there is not a special period to enroll in a Medicare Supplement like there is for Medicare Advantage Plans. One can change a Medicare Supplement any day of the year with qualifying medically with underwriting questions.

Readers do not cancel your Medicare Supplement plan for the first few months that you are trying a Medicare Advantage plan just in case you need to return to Original Medicare during MA OEP from January1through March 31.

During a Toni Says Medicare consultation, whether in person or by Zoom, the Toni Says Medicare agent always advises clients to call all of their doctors and ask which Medicare Advantage plans the healthcare professional or facility accepts. Not asking your eye doctor’s office prior to changing to the Medicare Advantage HMO  has caused this surgery postponement problem for you, Stephanie. Be aware that doctors, specialists, and facilities can stop accepting a particular MA Plan at any time.

For assistance with disenrolling from a Medicare Advantage plan that does not fit your needs and finding a Medicare Supplement, call the Toni Says Medicare office at 832-519-8664 or email Medicare questions to info@tonisays.com.

Toni’s new course, “Confused about Medicare Workshop,” a downloadable video series, and the “Medicare Survival Guide Advanced” edition are available at www.tonisays.com. Sign up for the Toni Says newsletter on the Toni Says website at tonisays.com to keep up to date with Medicare changes.

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Toni:

I never should have listened to my brother who bragged about how his Medicare Advantage plan was a great way to save money and not have to spend so much on my Medicare supplement plan’s premium. I discovered that the eye doctor who was to perform surgery on my right eye in early January is not in this plan. I should have called his office before I signed up for the HMO plan.                                                                                                                                               Now my eye surgery is postponed since the doctor’s office is requesting that I return to Original Medicare to do the type of surgery that is needed. Can you explain how and when I can return to Original Medicare? I am glad I had not cancelled my Medicare Supplement Plan G even though the premium has increased. Signed…Christina from Phoenix, AZ

Hello Christina:

Readers, if you have discovered you made the wrong choice in selecting a Medicare Advantage (MA) Plan, Jan. 1 begins the 3-month period allowing you to change to a different Medicare Advantage Plan or return to Original Medicare. Your changes will take place on the first day of the following month. Christina, if you drop your MA Plan in January, then you will return to Original Medicare on Feb. 1.

The 2025 Medicare & You Handbook discusses on page 72, the changes that can be made to Medicare Advantage Plan during the period, called the Medicare Advantage Open Enrollment Period (MA OEP), which runs from Jan.1 through Mar. 31 each year.

During the MA OEP, a person can switch from one Medicare Advantage Plan to another Medicare Advantage Plan, or to Original Medicare with or without a Part D plan. The main difference between Medicare Advantage Open Enrollment Period (MA OEP) and Medicare Annual Enrollment Period (AEP) is who can use each one: Only individuals on a Medicare Advantage Plan can utilize the Medicare Advantage Open Enrollment Period.

A person may not disenroll from a Medicare Advantage plan or a Medicare Part D prescription drug plan after Mar. 31, because one is “locked in” from Apr. 1 to Dec. 31. One must wait until the next Medicare Annual Enrollment Period (AEP), which occurs annually from Oct.15 through Dec. 7 to change to a different plan or return to Original Medicare.

You made a smart choice, Christina, in not cancelling your Medicare Supplement because, due to your health issues, you may not be able to qualify for a new Medicare Supplement plan. Most Americans do not realize there is no special period to enroll in a Medicare Supplement like there is for Medicare Advantage Plans. One may change a Medicare Supplement any day of the year with qualifying medical underwriting questions.

Readers do not cancel your Medicare Supplement plan for the first few months that you are trying a Medicare Advantage plan just in case you need to return to Original Medicare during the MA OEP from Jan.1through Mar. 31.

During a Toni Says Medicare consultation, whether in person or by Zoom, we always advise Medicare clients to call all of their doctors and ask which Medicare Advantage plans the healthcare professional or facility accepts. Not doing that has caused this surgery postponement problem for you, Christina.

Readers, remember to always talk to the doctor’s office manager before you make any changes to your Medicare insurance and verify what MA Plans the office accept. Also be aware that doctors, specialists, and facilities can stop accepting a particular MA Plan at any time.

For assistance in disenrolling from a Medicare Advantage plan that does not fit your needs and finding a Medicare Supplement, call the Toni Says Medicare office at 832/519-8664 or email Medicare questions to info@tonisays.com.

Merry Christmas from Toni and the Toni Says Medicare Team!!

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Toni,

I have Original Medicare with a Supplement and in October, I was taken by ambulance to the emergency room for heart issues. I was surprised when I signed a hospital form stating that I was “under observation,” as the doctor decided whether to admit me as an inpatient or send me home. I was lucky that he sent me home.

During this Medicare Annual Enrollment (AEP), my husband, Alan, enrolled in a Medicare Advantage HMO for the first time. Can you please explain how this rule could affect his hospital stay since he is no longer in Medicare with a Supplement. Please explain. Thank you.

–Sybil from Tampa, Fla

Hi Sybil:

The Medicare Outpatient Observation Notice (MOON) rule only affects those who are enrolled in “Original Medicare” with or without a Medicare Supplement. The rule does not affect those enrolled in a Medicare Advantage plan. On page 28 of the 2025 Medicare & You handbook, this rule is explained under, “Am I an inpatient or outpatient?”

A Medicare Advantage HMO plan, however, has its own process for inpatient and outpatient surgery, or hospital stay with a referral only system. With a Medicare Advantage PPO plan, there is not a referral process, but the facility or provider must be willing to bill the Medicare Advantage plan.

The Medicare & You handbook explains what a Medicare Advantage plan or what a Medicare Supplement/Medigap “Original/Traditional Medicare” is? But it does not compare the differences between the plans, as listed below:

Medicare Supplement

1. A Medicare Supplement/Medigap Plan works directly with Original/Traditional Medicare. Medicare will pay its share of the Medicare-approved amount for “medically necessary” covered healthcare costs. Then, your Medicare Supplement/Medigap will pay its share.
2. You can choose your doctor, hospital, home health agency, skilled nursing facility, etc., so long as it accepts Medicare assignment. You and your health care provider are in control of your health care.
3. With a Medicare Supplement/Medigap, you have a monthly premium that may increase in the premium rate each year.
4. You may enroll in and will pay separately for a “Stand alone” Medicare (Part D) Prescription drug plan.

Medicare Advantage Plan 

1. To qualify for the plan:

• You must be enrolled in both Medicare Parts A & B
• You must live in the service area 6 months out of a year

2. When you choose a Medicare Advantage Plan, then Medicare pays the insurance company a certain amount every month for your care for the plan you are enrolled in.
3. When you go to the doctor or visit your pharmacist, you must only use your Medicare Advantage insurance card, not your Medicare (red, white, and blue) card.
4. A Medicare Advantage Plan must provide all your Part A and Part B benefits, and most Medicare Advantage Plans have Part D prescription drug plans included. If the drug plan is included, you don’t have an independent choice in drug plans. The carrier who provides your health coverage also provides your drug coverage.
5. With a Medicare Advantage plan, you may have different co-pays, co-insurances, deductibles to pay and have maximum out-of-pocket expenses to meet.
6. Talk to your provider or facility and make sure they accept the Medicare Advantage plan you want to enroll in.

Readers, always make sure to read and understand your Medicare coverage, whether you have a Settlement or Advantage plan.  Remember, with Medicare, it’s what you don’t know that WILL hurt you! Especially, when the maze of Medicare is confusing you.

Call the Toni Says Medicare hotline at (832) 519-8664 or email info@tonisays.com for assistance. Toni’s books and webinar series are available for purchase at www.tonisays.com.

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Toni:

In August, my husband and I enrolled in a Medicare Supplement, which has not paid a medical claim because we are in a Medicare Advantage plan. We could not leave the Advantage plan and return to Original Medicare due to Medicare rules.

I was told that Medicare’s Annual Enrollment is when Sonny and I can disenroll from this Advantage plan and return back to Medicare, but I do not know what to do.

Toni can you please explain in simple terms what we need to do since Medicare’s enrollment period is beginning. Thanks, Laura from Las Vegas

Hello Laura:

The biggest no-no in the Medicare insurance world is when an insurance agent sells a Medicare beneficiary (which is what you and Sonny are) who has a Medicare Advantage plan a new Medicare Supplement without advising the client how to disenrolled properly from their Medicare Advantage plan.

Medicare’s Annual Enrollment (AEP) from Oct. 15 to Dec. 7 is the proper time to disenroll from the Medicare Advantage plan that you and Sonny are currently in by enrolling in a Medicare Part D plan and return to Original Medicare on Jan. 1. At that time is when you can begin to use the Medicare Supplement which you applied for in August.

AEP is the time when one can enroll or change either a standalone Medicare Prescription Drug (Part D) plan or a Medicare Advantage (Part C) plan with or without a prescription drug plan. Enrolling in a Medicare Supplement or changing Medicare Supplement plans is not included in Medicare’s AEP rules. Underwriting rules for Medicare Supplements will apply during AEP.

Below are changes that can be made during Medicare’s Annual Enrollment Period (AEP):

• Return to Original Medicare by enrolling in a stand-alone Medicare Prescription Drug (Part D) Plan. (Laura, this is you and Sonny’s Medicare AEP option to begin using the Medicare Supplement which you enrolled in August.)
• Return to Original Medicare by enrolling in a standalone Medicare Prescription Drug (Part D) Plan and purchase a Medicare Supplement. (underwriting rules may apply)
• Enroll in a Medicare Prescription Drug (Part D) Plan.
• Change from one Medicare Prescription Drug (Part D) Plan to a new       Part D Medicare Prescription Drug Plan.
• Enroll in a Medicare Advantage (Part C) Plan with Prescription Drugs
• Change from one Medicare Advantage (Part C) Plan with or without Prescription Drug plan to a new Medicare Advantage (Part C) Plan.
• Return to Original Medicare only and enroll in a stand-alone Medicare Prescription Drug (Part D) Plan.
• Or Return to Original Medicare with no Part D plan. *Please note there is a penalty for not enrolling in a Medicare Prescription Drug (Part D) plan when first eligible.

For those who already have either a Medicare Advantage (Part C) plan with or without prescription drugs or a standalone Medicare Prescription Drug (Part D) plan, Medicare’s Annual Enrollment is the time to make sure your drug plan or Advantage plan still meets your needs.

It has been acknowledged that some Medicare Advantage and Part D plans have changed for 2025. Use www.medicare.gov to verify that your prescription drugs are covered in your 2025 MAPD or Part D plan formulary. If your prescriptions are not covered for 2025, you will have to pay 100% of that prescription cost out of your pocket.

With Medicare, it’s what you DON’T know that will HURT YOU! Need Medicare help? Call the Toni Says Medicare hotline at (832) 519-8664 or email info@tonisays.com for assistance. Toni’s books are available at www.tonisays.com with a bundle discount for Toni Says® readers.

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Hello Toni:

Thank you for teaching us the value of finding the right Medicare option for my husband Clint and me. When he retired at age 70 a few months ago, Clint was determined to go with Medicare Advantage PPO plan because it had a $0 monthly premium and thought there was no difference between a Medicare Supplement and a PPO plan except cost.

Last week Clint received a life-changing diagnosis of terminal lung cancer. Had we chosen the PPO Advantage route, then Clint and his medical team would not be in control of his health care. Please let your readers know of our situation because health care needs can change in a flash, like Clint’s did! Thanks, Raquel, from Springfield, MO.

Hi Raquel:

Americans need to understand that there are differences between Original Medicare and a Medicare Supplement and Medicare Advantage PPO Plans other than the premium.

With Original Medicare, there is not a network of any kind; you have the freedom to use any health care provider/facility that will bill Medicare. The Medicare Supplement that you enroll in will pay for the out-of-pocket costs not covered by Medicare Parts A and B.

With a Medicare Advantage PPO (MA PPO) plan with low premiums, there are lower costs for in-network providers/facilities but higher out-of-pocket costs for out-of-network benefits. To review 2025 Medicare Advantage (MA) PPO plan out-of-pocket costs, check your new 2025 Medicare & You handbook or search www.medicare.gov.

Most people on a MA PPO plan never consider they may pay an out-of-network health care provider/facility for their medical claim. In these changing medical times, many providers or facilities are out of network nationwide with a MA PPO plan.

Below are differences between a Medicare Supplement and Medicare Advantage PPO plan:

–Medicare Supplement:

• Medicare Supplements work directly with “Original” Medicare. Medicare pays its share of the Medicare-approved amount for “medically necessary” covered health care costs.
• The Supplement you pick will pay its share of the medical claim for the health care provider/facility providing the medical care.
• Medicare Part D prescription drugs plans are not included in a Medicare Supplement. It is important to have your “stand alone” Medicare (Part D) prescription drug plan to begin the same month the Supplement does.
• The downside to a Medicare Supplement is the monthly premium can increase each year.

–Medicare Advantage PPO Plan:

• To qualify for any Medicare Advantage plan, you must be enrolled in both Medicare Parts A & B and must live in the service area 6 months out of the year.
• Medicare pays the insurance company a specific dollar amount every month for your medical care to the Medicare Advantage Prescription Drug (MAPD)plan you are enrolled in.
• When you go to the doctor, hospital or visit your pharmacist, you must only use your Medicare Advantage Plan insurance card, not your Medicare (red, white, and blue) card.
• A Medicare Advantage Plan must provide all your Part A and Part B benefits, and some Medicare Advantage Plans have Part D prescription drug plans included.
• “Extra” benefits such as gym membership, dental and vision may be offered.

Readers, as Raquel and Clint discovered, your health care needs can change overnight. Review your options carefully, because with Medicare, it’s what you don’t know WILL hurt you!

Want to know what the changes for this year’s Medicare AEP are? Attend Toni’s Confused about Medicare AEP Zoom Workshop which is “Live, Free and Nationwide” Wednesday, October 23 at 4:00PM CST. To register by Zoom, visit www.tonisays.com or call 832/519-8664 for more information.

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