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Dear Toni,

My parents went into a local independent living facility, and I have received an email from the facility’s executive director with information detailing how to draw up an emergency evacuation plan. The executive director asked that those living in the facility submit a personal “Emergency Evacuation Plan” by June 1 because that is when hurricane season” begins for America.

We need your guidance to prepare an emergency evacuation plan to submit to the executive director .  Thanks, Toni.

Andy from Beaumont, Texas

Hello Andy:

Monday, June 1 is when the 2026 hurricane season begins nationwide and it does not end until Monday, November 30. As America gets deeper into the season, the storms can get stronger. No one expects life to change in an instant, but it can.

Everyone in a position to be affected should have a family emergency evacuation plan for hurricanes, tornadoes, earthquakes, and other disasters. A plan is crucial for the elderly or those who are disabled, that are dependent on different types of medical needs or assistance such as kidney dialysis, oxygen, wheelchairs, walkers, etc., for their life support or ongoing medical treatment.

Below are a few questions to help you to prepare for designing your family’s emergency evacuation plan for any type of an emergency, disaster, or hurricane/tornado:

• Do I stay or go? This will depend on where you live. If you live in a city or other highly populated area, leave early. During past storms such as Beryl in the Houston area, people were caught in massive traffic jams, waiting on the highway for hours or days to evacuate. Leaving early will help you avoid serious delays and avoid running out of gas while stuck in traffic.

1. a) Make sure you have a sufficient supply of prescriptions and always bring a list of current prescriptions for elderly family members and yourself.
2. b)   Have a copy of medical records for those with critical medical conditions. Keep the medical records in a safe place that you can get to immediately when evacuating.
3. d) Include all legal documents such as Medical Power of Attorney and Living Will.
4. c) Have a backup plan in case you are out of town during an emergency, so other family members can help take over the proper care for your elderly or disabled loved ones.

• Do I have access to clean water? If you do not have access to clean water, then any crisis becomes critical within a few days. Remember, you may not have access to a grocery store, or, even if you do, its supplies may be depleted. Start stocking up on bottled water.
• Do I have an adequate food supply? Most households have a few days of food already available, but the best way to stock up on additional food and supplies is to add a little bit extra each week. Remember that during an emergency, the power may be out, so cook your frozen and refrigerated food first. Have extra propane tanks for a gas grill available.
• Do I have enough cash on hand? Keep your parents or your current checkbook with you in case you run out of cash and the ATMs are not operating.
• Does my family know where to meet? It is important that all family members and loved ones know where to meet in a disaster.

After Hurricane Beryl devastated the Houston area on July 8, 2024, Texans learned that we cannot take storms and natural disasters lightly. Limited access to essential supplies such as water, groceries and baby formula affected us. I personally lost power for over a week and had to stay at my son’s house, sleeping on the couch because he did have power.  What a true blessing!

Questions? Contact the Toni Says Medicare team at info@tonisays.com or call (832) 519-8664 for assistance or to answer Medicare questions. Sign up for the Toni Says newsletter at www.tonisays.com to download Toni’s new Medicare 2026 First Steps guide.

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Dear Toni,

I turn 65 in April, am covered under my wife’s employer’s health insurance and am fighting liver cancer. I am participating in a clinical trial for a cancer medication which costs over $12,000 per month and am paying $0 for a medication that is curing my cancer.

I am concerned about what to do when I enroll in Medicare and if I will be in Medicare’s “donut hole” since this is a clinical trial. I am not planning on enrolling in Medicare until my wife, Sarah, retires when she turns 65 in 2 years.

Are clinical trial prescriptions covered under Medicare’s drug plans? What are my options?

Thanks!   Lee from Jackson, Miss.

Hello Lee:

What a smart decision you made to stay on Sarah’s employer benefits, because both you and Sarah can enroll in Medicare Parts A and B when she retires in 2 years at 65. At that time, you will be eligible for a Special Enrollment Period (SEP), avoiding the famous Medicare Part B penalty, and will be able to enroll in a Medicare Part D prescription drug plan. She will be enrolling in Medicare during her Initial Enrollment Period (IEP).

I have good news for you!  Medicare’s “donut hole” went away in 2025, and now  there is a specific drug plan maximum out of pocket every year.

Lee, Medicare’s Part D maximum out of pocket for 2026 which is $2,100, and you would qualify for that when you order the cancer drug costing over $12,000 per month if that prescription is in the formulary for the Medicare Part D plan you enroll in when you are no longer covered by Sarah’s employer health insurance. If that specific cancer drug is not approved for clinical trial and not covered by the Part D plan you enroll in, then you may have to pay the $12,000 per month.

Enroll in the Medicare Part D plan that covers all of your prescriptions, even though the most expensive prescriptions are those covered by a clinical trial program and currently costs you nothing. There may be a time when those expensive prescriptions are no longer covered by the clinical trial, and without the right plan you will experience paying that year’s Part D maximum out of pocket. Each year, Medicare changes the Part D prescription drug deductible, copays, and maximum out of pocket.

Whether your Part D prescription drug plan will pay for a medication used in a clinical trial depends on whether it is covered in the plan’s formulary or can be classified as a highest-tier  prescription  drug, which costs more. Then you will go into that year’s Medicare Part D’s maximum out of pocket.

*Beware: If you are not enrolled in a Part D plan that covers the expensive clinical trial prescriptions, then you will pay 100% out of your pocket for the expensive prescriptions that are not covered when the clinical trial ends.*

For those enrolled in a Medicare Advantage plan seeking clinical trial, page 35 of the 2026 Medicare & You handbook under “Clinical Research Studies” states, “If you’re in a Medicare Advantage plan, Original Medicare may cover some costs along with your Medicare Advantage plans. Contact your plan for details about coverage for Clinical Research Studies.  This short section also explains how different types of medical care are covered under Medicare Parts A and B.

Lee, enrolling in Medicare Part B when your wife retires is a good option. Both you and Sarah will qualify for a Medicare Supplement/Medigap Plan during your 6-month Medigap Open Enrollment Period without having to answer one health question. This period starts the month your Medicare Part B is effective.

Take your time and research which Medicare options meet your needs because with Medicare what you don’t know WILL hurt you! Exploring Medicare Part D and prescription drugs is one of the most important topics during a Toni Says Medicare consultation.

Email info@tonisays.com or call 832-519-8664 with your Medicare question or to schedule a Medicare consultation.  Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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Hi Toni:

I recently enrolled in Medicare. This week, I went to see my primary care doctor and his office manager informed me that they are no longer accepting Medicare. Instead, I will have to pay the complete bill up front and be reimbursed by Medicare. His office is small, and the doctor will be retiring soon. I will need to find a new doctor.

Toni, can you please explain what I need to do to submit the doctor bill to be reimbursed by Medicare?

— Beth from Lubbock, Texas

Hello, Beth:

I am hearing about this problem from the Medicare clients, who come to the Toni Says office for a consultation, saying that a few of the primary care/medical providers are retiring. The office paperwork, whether it is for Medicare-age patients or those under 65 medical claims, is very overwhelming. These offices do not accept Medicare, as your doctor is doing, and will not bill Medicare. The medical provider’s office wants their patients to submit the claim to Medicare and wait to be reimbursed.

Beth, did the doctor’s office charge you full rates and have you pay when leaving the appointment? And then you had to file with Medicare and be reimbursed from Medicare what Medicare pays rather than what doctor charged you? I have not heard of this problem with larger medical offices, especially those that are part of a hospital system.

My advice to Toni Says clients who are new to Medicare is to begin searching for medical providers that accept Medicare, especially for those on Medicare who have a serious health issue.

Below are a few Medicare tips when filing a medical claim that can help you:

• Before you set the appointment for your medical visit, ask the doctor’s office if they are still accepting Medicare. Most important, if this is a new doctor’s office, ask whether that office is accepting “new Medicare patients” and whether that office will bill Medicare directly.

If the doctor’s office says “no” to the second question, Beth, you need to decide:

1. Do you want to pay out of pocket and be reimbursed only what Medicare pays? Remember, doctors know they are not paid their asking rates. Medicare is not the only insurance plan that discounts the doctor’s bills. Group and individual health insurance plans with network providers also discount the doctor’s bills.

Or…

1. Do you want to look for a doctor or specialist who accepts Medicare assignment and bills Medicare directly? (Again, you should verify that the office is accepting new Medicare patients.) Ask your current primary care doctor for more than one doctor or provider that he/she recommends for your specific medical situation.

If your doctor does not accept Medicare, it is not hard to file a claim. You may have to pay the complete bill and send the claim to Medicare. Make a copy of your medical bill to send to Medicare, along with any information about your medical claim.

Visit Medicare.gov and in the search bar type “filing a claim.” The information provided will explain how to submit a claim and to download the claim form CMS-1490S, “Patient’s Request for Medical Payment”. The CMS-1490S form has instructions about submitting the form with an itemized bill and supporting documents. The form also lists by state where you need to send everything. Beth, if you need help filing a claim call Medicare at 800-MEDICARE (633-4227) and ask the Medicare agent for help filing the claim. Medicare will be happy to help.

Need additional help understanding Medicare? Toni’s new course, a downloadable video series called the “Confused about Medicare Workshop,” and the “Medicare Survival Guide Advanced” edition are available at www.tonisays.com.

For answers to your Medicare questions and retiring issues, call the Toni Says Medicare team at 832-519-8664 or email info@tonisays.com. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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Hello Toni:          

In the new Medicare & You Handbook that I received about a month ago, I cannot find what the 2026 Medicare costs and premiums will be. I would like to know this information because I have been diagnosed with a heart condition and will need to undergo a heart surgery next year. I have looked online and cannot find the costs there either.

Do you have any idea what the 2026 Medicare costs will be?

Carol from Sugar Land, Texas

Hello Carol:

Every year the Medicare & You Handbook is mailed out before October 1to all Medicare beneficiaries to help guide them through the Medicare Open Enrollment Period (OEP) period which ends December 7. This year’s handbook states that at the time of printing, the premiums, and deductible amounts for Medicare Part A, Part B and Part D were not available.

The Centers for Medicare and Medicaid Services (CMS) released the 2026 Medicare costs last Friday, November 14, with an increase for both Medicare Parts A and B premiums and deductibles.

Below are the 2026 Medicare Part A and B premiums and deductibles, as well as information on the 2026 Medicare Part D changes that affect Medicare’s Part D prescription drug costs.

2026 Medicare Parts A and B premiums and costs:      

• Part A Costs (Inpatient Hospital): The new 2026 Part A inpatient hospital deductible will be an increase of $60, from $1,676 in 2025 to $1,736, for 2026. The Part A deductible starts over every 60 days. It is not a once-a-year deductible but  six times a year. Skilled Nursing is included under Part A, and the 2026 costs will be $0 copay per day for days 1-20 and $217.00 per day for days 21-100.
• Part B Costs (Medical): The new 2026 Part B medical/doctor deductible will increase by $26 from the $257 deductible in 2025 to $283 beginning Jan. 1, 2026. After the deductible is met, Medicare pays 80% of the Medicare-approved amount and the Medicare beneficiary pays the remaining 20% of the Medicare-approved amount.
• Part B Premium: The premium for 2026 has an increase of $17.90 from $185 in 2025 to $202.90 beginning Jan.1, 2026. Those with an income higher than $109,000 as an individual or $218,000 as a married couple will pay more for their Medicare Part B premium beginning Jan. 1, 2026. The premiums for higher income earners were also released on Nov.14 and can be viewed at www.cms.gov/newsroom/fact-sheets/2026-medicare-parts-b-premiums-deductibles.

2026 Medicare Part D costs and co-pays:

• Initial Deductible: will increase by $25 from $590 in 2025 to $615 beginning Jan.1,2026.
• Initial Coverage: has 6 drug-tier stages; the Part D plan pays its share of the cost of your drugs, and you pay your share until the maximum amount of $2,100 out-of-pocket is met. Then you move into the Catastrophic Coverage stage and pay $0.
• Total Out-of-Pocket: Effective Jan. 1,2026, the maximum out-of-pocket will be $2,100.

Jan. 1 of each year, the Part D process starts all over again with a new Medicare Prescription Drug plan and a new initial deductible and maximum initial coverage limit.

Medicare’s Prescription Payment Plan, which began Jan. 1,2025, is a payment option available to help manage the $2,100 maximum out-of-pocket drug costs by spreading your monthly prescription drug costs throughout the year from January to December. For more information about the payment plan, visit www.medicare.gov or call your Medicare Part D plan.

Readers, your prescription drug needs can change with each yearly Medicare Open Enrollment Period. Chapters 5 and 6 of Toni’s Medicare Survival Guide Advanced edition explains Medicare Part D and Medicare Open Enrollment Period in “easy to understand” terms.

Review your Medicare options carefully, because with Medicare, what you don’t know WILL hurt you!  Have a Medicare question, email info@tonisays.com or call 832-519-8664. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

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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’m enrolled in Medicare but have not received my Medicare & You Handbook. I need to make some changes, and I’m concerned about what I should do during the fall Medicare season. I need to know which options are right for me. I have some health problems, and I’m concerned that I might make the wrong change to my Medicare and Part D plan.

I know that I will be bombarded by marketing material, and I would really appreciate any advice that you can give me in advance. Thanks, Toni.

— Sylvester from Richmond, Texas

Hello Sylvester:

The 2026 Medicare & You handbook will be mailed to over 65 million Medicare beneficiaries in September to arrive before October. It’s amazing how efficient Medicare is to have these handbooks arrive every year in time for Medicare’s Open Enrollment Period (OEP)/Annual Enrollment Period (AEP).

Sylvester, you have time to do the correct research because Medicare’s OEP/AEP period begins enrolling America Wednesday, Oct.15, and ends enrollment at midnight on Sunday, Dec.7. (Medicare’s OEP/AEP enrollment period is discussed at length in Chapter 6 of my book, Medicare Survival Guide Advanced edition.)

Readers, please take your time researching your options especially if, like Sylvester, you have health issues.

Below are the steps a Toni Says Medicare team member uses when helping clients during Medicare’s OEP/AEP:

Step #1: Decide whether you want “Original Medicare” (Parts A & B) or a “Medicare Advantage”          (Part C) plan.

1. Ask your doctor’s office which plan it recommends. Most doctors accept “Original Medicare,” but not all accept Medicare Advantage HMO or PPO plans. If you have a doctor that is in a Medicare Advantage plan’s provider directory, make sure you call to verify that the physician’s office will still be accepting that specific Medicare Advantage plan in the upcoming calendar year.
2. The main difference between “Original Medicare” and Medicare Advantage plans is that “Original Medicare” is administered by Medicare, and the Medicare Supplement plan that’s selected pays the Medicare deductibles or coinsurances. Medicare Advantage plans are administered by private insurance companies that are approved by Medicare.
3. If you choose a Medicare Advantage plan, you must use that specific insurance company’s card, not your Medicare card.

Step #2: Decide whether you need to enroll in or change your current Medicare Part D (prescription drug coverage) plan during Medicare’s OEP/AEP enrollment time.

1. If you want Medicare Prescription Drug coverage to go along with Original Medicare, then you must enroll in a stand-alone Medicare Part D plan and there may be a monthly premium.
2. If you choose a Medicare Advantage plan, make sure that the plan has Medicare Part D Prescription Drug coverage included to keep from receiving a Medicare Part D penalty for not enrolling in a Medicare prescription drug plan.
3. Whichever plan you chose verify that all prescriptions, both brand name and generic, are covered under the Part D’s plan formulary.

Step #3: Remember, you have from Oct. 15 to Dec. 7 to change or enroll in a new Part D plan for your Medicare Advantage plan or stand-alone Medicare Part D plan which both begin Jan. 1.

1. If you miss the deadline of Dec. 7, you will have to wait until the next year’s Medicare OEP/AEP enrollment time.
2. Medicare’s OEP/AEP is only for enrolling or changing Medicare Advantage Part D or stand-alone Medicare Part D plans. One can change Medicare supplements, long term care, or dental plans any time of year.

Remember…with Medicare, what you don’t know WILL hurt you! Take your time during Medicare’s OEP/AEP to explore your Medicare options. Call the Toni Says Medicare hotline at (832) 519-8664 or email info@tonisays.com for assistance with Medicare issues. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date with Medicare changes.

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Toni:

I have been researching the changes to Medicare’s telehealth services over a computer video service that I saw on the news recently. I am concerned because my mother lives in an assisted living facility and her primary care doctor uses the telehealth computer service, so I do not have to take my mother, who uses a wheelchair to the doctor by a health care taxi service or ambulance.  Since the pandemic, this type of care has been approved by her Medicare Advantage HMO.

The social worker at mother’s living facility suggested that I discuss with her Advantage plan to discuss whether there are any house-call physicians who can accept her as a patient.  Is this something that Medicare or her Medicare Advantage plan will pay for?

Should I consider changing my mother from her Medicare Advantage HMO to “Original Medicare with a Medicare Supplement” due to her health issues? Thanks for your help.

–Sheila from Little Rock, Ark

Hi Sheila:

Last week Medicare changed the date when “telehealth services” will ONLY be made available locally and in a rural area. From today through September 30, 2025, you can get telehealth services at any location in the U.S., including your home. The Medicare.gov website states, “starting October 1, 2025, you must be in an office or medical facility located in a rural area (in the U.S.) for most telehealth services”.

The Medicare.gov website also states that if you aren’t in a rural health care setting, you can still get certain Medicare telehealth services on or after October 1, including:

• Monthly end-stage renal disease (ESRD) visits for home dialysis
• Services for diagnosis, evaluation, or treatment of symptoms of an acute stroke wherever you are, including in a mobile stroke unit
• Services for the diagnosis, evaluation, or treatment of a mental and/or behavioral health disorder (including a substance use disorder) in your house

My advice to you, Sheila, is to ask your mother’s primary care physician or specific Medicare Advantage plan’s healthcare provider which house call or Accountable Care Organization (ACO) they are contracted with.

Not only are doctors making house call visits, but dentists, eye doctors and even mobile x-ray/ultra-sound machines with technicians are visiting nursing homes, assisted living facilities and personal care homes, just like these providers were doing before COVID-19.

A house call physician visit can keep those who are having a minor ailment from turning into a major health care issue keeping a frail senior healthy and out of the hospital.

Doctor or medical provider visits by house call services–whether at home or at a long-term care facility such as a nursing home, assisted living facility or personal care home– are being accepted and paid for by Original Medicare, Original Medicare with a Medicare supplement and Medicare Advantage plans (if the house call provider is in the Advantage plan’s network).

Sheila, you are wise to look at all your mother’s options regarding disenrolling from her Medicare Advantage plan with her serious health situations. Many do not realize that they must qualify medically to be approved for a Medicare Supplement, which helps pay the portions that Medicare does not pay. If one is not approved, then they will pay out of their pocket.

Readers, it is important to explore your Medicare plan options, because you never know when your health will deteriorate, becoming too late to change your Medicare plan. Chapter 2 of Toni’s Medicare Survival Guide Advanced edition explains Medicare Parts A and B, which can help avoid problems.

Contact the Toni Says Medicare team at www.tonisays.com for immediate assistance or call the Toni Says hotline at (832) 519-8664. The Confused about Medicare online video course is also available through our website, to help America understand the complexities of Medicare enrollment, whether turning 65 or retiring past age 65.

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Hello Toni:

I am a human resources manager for an oil service company and have a question about an employee. He is turning 65 and is still working full time. His situation is unusual because next month he will begin receiving chemotherapy for lung cancer. I am not sure how to advise him because, technically, he is working full-time. He has accrued 5 months of paid vacation time, which he can use while recuperating that keeps him as a full-time employee.

Our firm has over 100 employees, and I’ve been told there are certain rules for a specific company size. How can I make sure that I have the correct answer to my questions for the employees of our company? Thanks, Toni   Beth from Houston, TX

Hi Beth:

Most of the answers about enrolling in Medicare are in the Medicare & You handbook. Many Americans do not take Part B during their Initial Enrolment Period (IEP) when turning 65 because they or their spouse are “still working” with health insurance provided from a current employer. Beth, the IEP for your employee who has cancer begins three months before his 65^th birthday and ends three months after his 65^th birthday.

Since your employee is still working full-time with employer benefits, I would advise him not to enroll in Medicare until he is no longer working full-time. What a blessing to have 5 months of pay by not using his vacation time. You never know when you may need a leave of absence due to health issues.

Beth, understanding are a few Medicare enrollment options that can help to make your job easier. You should:

• Verify your employees’ options by calling your company’s health insurance plan and ask how the plan coordinates with Medicare.
• Review page 19 of the 2025 Medicare & You handbook under “Should I Get Part B?” to determine if delaying Part B enrollment past 65 is an option for your employees. (Chapter 1 of Toni’s new Medicare Survival Guide Advanced edition which is available at tonisays.com, also discusses this situation.

You should also review a few of the Medicare rules that decide whether Original Medicare or other insurance pay first. See the chart regarding the number of employees on page 21also in the 2025 Medicare & You handbook under “How does my other insurance work with Medicare?”

• If there are 20 or more employees at the company where you or your spouse currently work and get benefits, your group health insurance pays first.
• If there are fewer than 20 employees at the company where you or your spouse currently work, and receive benefits, Medicare pays first. The Human Resource department should verify with the insurance carrier as to how the plan coordinates with Medicare and if the employees should enroll in Medicare Parts A and/or B when turning 65.

Employees should contact their local Social Security office immediately to enroll in Medicare Part B when their work status changes after 65. The employee who has the health issue will need to enroll during a SEP (Special Enrollment Period) when his employment changes from full time to a part time employee, when he decides to retire, or if he is terminated.

Those who decide to enroll in COBRA need to know that COBRA and retiree insurance are not considered current employer insurance. Employees will not have a SEP with these plans if they wait too long.

Beth, when the employee is leaving employment past 65, it is important to have the human resource department complete and sign the CMS-L564 (Request for employment information) form and attach it to CMS-40B (Application for enrollment in Medicare Part B). Write “Special Enrollment Period” across the top of each page, then have the employee file both forms, preferably “in person” with the specific local Social Security office.

The employee should advise the Social Security representative that they and also their spouse (if the spouse is on their insurance and losing employer benefits) need Medicare Part B to begin ASAP. Write the effective day on the CMS-40B as the first of the month in item #9 of the “Remarks” section of the application.

Beth, you are a good HR manager to be looking out for your employees, because when it comes to Medicare, what they don’t know WILL hurt them. Contact Toni Says Medicare team at info@tonisays.com or call 832/519-8664.

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Hello Toni,

When I turned 65, I continued to work with excellent company benefits. I delayed enrolling in Part B for 5 years after I turned 70 and retired with a Jan. 1 effective date for my Medicare Supplement Plan G and Part D prescription drug plan.

Now my Medicare stress has started, because I have received a notice from CMS saying they do not have record of me having prescription drug coverage that “met Medicare’s minimum standards” from March 1, 2019, when I turned 65 to Jan. 1, 2025, when I retired, and I may receive a Part D late enrollment penalty.

I thought applying for Part B with that form from my employer attached kept me from a Part D penalty. Can you please advise me what to do? I want to be sure that I do not make a mistake. Thank you, Toni.
— Zach, Lake Jackson, TX

Hi Zach:

Many Americans who retire after 65, leaving employer group health plans, apply for Medicare benefits and discover that they now may need to prove they had “creditable drug coverage” for a Medicare Part D prescription drug plan.

Zach, enrolling in Medicare Part B properly does not prove that your employer’s group prescription drug plan was creditable. The Medicare & You handbook states:
“Creditable prescription drug coverage could include drug coverage from a current or former employer or union, TRICARE, Indian Health Service, the Department of Veterans Affairs, or individual health insurance coverage. Your plan must tell you each year if your non-Medicare drug coverage is creditable coverage.” … Keep records showing when you had other creditable prescription drug coverage and tell your plan when they ask about it. If you don’t tell your plan about your previous creditable prescription drug coverage, you may have to pay a penalty for as long as you have Medicare drug coverage.

The paragraphs above do not advise what creditable coverage is. To explore for more details on “creditable prescription drug coverage” visit www.medicare.gov or email info@tonisays.com with your Medicare questions.

Creditable drug coverage should “meet or exceed” Medicare’s Part D plan minimum. The minimum deductible for 2025, as an example, should at least be $590 or less (this amount changes every year) with a maximum out-of-pocket. The benefit amount should be unlimited, so if your plan has a coverage limit or cap, it is not creditable. Unlimited prescription drug coverage is the key.

Medicare does not regard discount prescription drug programs from Walmart, Kroger, GoodRx, Amazon pharmacy or your local pharmacy that offer low-cost generics as “creditable coverage.” If you believe these plans can keep you from the Late Enrollment Penalty (LEP), I need to tell you that you’re WRONG!! According to CMS (Centers for Medicare and Medicaid Services), these types of prescription drug programs are not creditable.

For Veterans using the VA for prescriptions, I have good news for you – Medicare does consider the VA pharmacy to be creditable coverage.

Medicare can impose the Late Enrollment Penalty (LEP) because:
• Your company prescription drug benefits are not considered creditable as Medicare declares.
• You fail to call and confirm that your company prescription drug benefits were creditable, if requested via correspondence from your Part D plan.
• You had no creditable coverage and never enrolled in Medicare Part D when you were first eligible.

If you wait longer than 63 days without creditable prescription drug coverage when leaving company benefits and are older than 65 years and 90 days old, you may be assessed a LEP which is 1% for each month back to the month your Part A began, not from when your Part B begins. (Chapter 5 of my Medicare Survival Guide Advanced edition explains Medicare Part D and how to avoid Part D penalties).

Zach, you need to find the record from your previous (employer) plan showing that your prescription drug coverage was “creditable” and submit it when your new Part D plan.

Remember, with Medicare it’s what you don’t know that WILL hurt you! Email info@tonisays.com or call 832/519-8664 with any questions.

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