Morning, Toni:

Recently, you wrote a Medicare column about various life policies available after 65 and I have a retirement insurance question.

In January, I’m retiring when I turn 70 and my wife, Anna, will be 68. Our retirement insurance issue is that recently we applied for a long-term care plan and were both denied due to our health issues. I had my prostate removed due to cancer about 5 years with no current issues and Bonnie has AFIB which is under control. The agent writing the long-term care plan said that those past 60 years old find it difficult being accepted by an LTC plan due to health issues like we have.

My brothers and I are paying an Alzheimer’s assisted living facility over $12,000 a month for our father’s care. Are there long-term care options available for Anna and me with our health issues because paying $12,000 a month will drain our retirement.

Thanks, Paul from Tulsa, Okla.

Hi Paul:

I’m glad that my article about life insurance plans past 65 caught your attention and you took the time to email me about your long-term care situation. New short-term care plans that have extended care benefits have been developed assisting Baby Boomers when there is a need for extra help with unexpected health or accident issues.

The 2026 Medicare & You handbook, under “Paying for long-term care,” discusses how important it is to plan properly to maintain your independence and receive the proper care in the facility you desire. Medicare only pays for medically necessary skilled nursing facility care or for home health care if you meet certain conditions. Skilled nursing has 100 days of benefit with days 1-20 having a $0 copay per day and days 21-100 with a specified copay per day. If you cannot qualify or do not meet Medicare’s qualification for skilled nursing, you will pay 100% of the cost out of your pocket. Medicare doesn’t cover non-medical long-term care. This is why purchasing a policy to help with a long-term need becomes essential.

Let’s discuss options that can help to protect your finances from excessive long-term care costs. Especially for those who have health issues that can keep one from being accepted by a long-term care plan.

• Short-term care insurance plans have a simple health questionnaire with yes/no questions, making it easy to qualify. These policies will assist paying for nursing home, assisted living and personal care home as facility care with benefits for care in your house. Providing various options ranging from $50-$400 per day with benefit periods ranging from 1 or 2 years depending on plans. Allowing one to not drain their retirement dollars due to a serious illness recovery.
• Life and Annuity Policies are insurance policies that have a provision if you need long-term care; you can receive a certain amount of long-term care with your life/annuity policy’s face (Health questions may keep one from qualifying.)
• Aid and Attendance benefits is a VA benefit that can help Veterans with long-term care issues. There is over $20 Billion dollars available for long term care pension money just waiting for America’s Veterans to apply for their Aid and Attendance benefits. The must be a long-term care issue to qualify.

Important note: If you are under 60 and in good health, please take your time to apply for a traditional long-term care policy. It is easier to qualify and receive a lower premium whether annual or monthly. Most Americans retiring are concerned about a chronic illness being their biggest retirement expense if not planned for properly.

If you have long-term care or Medicare questions, please feel free to reach out to the Toni Says Medicare team at 832/519-8664 or send an email to info@tonisays.com. 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 need your assistance to enroll in Medicare because I am past 65 and still working full-time with employer benefits.  Sherry, the office manager, from my cancer doctor’s office, said that the employer’s health plan denied the recent claim for my cancer treatment. The health plan considers it to be “experimental” and will not approve paying for this care.

The specific cancer treatment costs me over $15,000, which I had to pay on Friday from my 401k.  This amount will drain what I need for retiring.  To remain as a full-time employee, I am having to use my 12 weeks of vacation time for this cancer treatment and receive my full pay.

Sherry said her office currently has patients on Original Medicare with a Medicare Supplement that is paying for this cancer claim. She files their claims without a problem. Toni, I need to know how to begin my Medicare benefits as quickly as possible. Please advise me what I need to do. Thanks, Toni.

— Brent from Nashville, Tenn.

Hello Brent:

A health care professional advised me that many of the new cancer procedures are not approved by individual and employer group health insurance plans. The doctor said that these procedures are generally approved with “Original Medicare.”  He agreed with me that enrolling in Medicare past 65 and employed is complex, especially when an employee has the health issues you are currently experiencing, Brent.

Below are Medicare scenarios for enrolling in Original Medicare past 65, while employed and leaving employer benefits.  They are the same whether you’re still working, laid off or retiring:

• Health issues are not covered by an employer health plan: You (or your spouse) are still working with health issues (like Brent), and the employer health insurance plan is not covering the doctor’s procedure. Even though you are not retiring, you need to enroll in Medicare.
• Laid off: You (or your spouse) are laid off and need to enroll in Medicare.
• Retiring past 65: You (or your spouse) decide to retire past 65 and need to enroll in Medicare.

The process to enroll in Medicare past 65 must be followed correctly , and is listed below:

1. Two(2) Social Security forms to file: 1) Medicare Request for Employment Information (CMS-L564) must be signed by the employer’s human resource representative for you and/or your spouse covered by employer benefits. 2) Request for Enrollment in Medicare Part B (Medical Insurance)(CMS-40B) must be filled out and signed by you (and your spouse if they are also enrolling in Medicare). These two forms are available at the Social Security website (www.ssa.gov/forms).
2. At the top each of these forms1) Request for Employment Information (CMS-L564) and Request for Enrollment in Medicare Part B (Medical Insurance)-(CMS-40B) form, it is very important to write “Special Enrollment Period” to inform the Social Security agent processing the form that you are signing up at the right time and prevent a Medicare Part B penalty. *If you have had two or more jobs since turning 65, then each of those companies must sign a CMS-L564 form.*
3. Always make copies of your completed forms CMS-L564 and CMS-40B and be sure to write “Special Enrollment Period” at the top of each application.
4. It is important to deliver the original forms to your local Social Security office especially when you want your Medicare to begin ASAP. There can be a delay in processing the forms when they are emailed or faxed. Keep your copies of the paperwork in case the paperwork is lost at the Social Security office.

Brent, as I have explained that there are options for enrolling in Medicare that many needing Medicare help are not aware exist. Because with Medicare, what you don’t know will HURT you!

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,

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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Toni:

On March 5, I received a Medicare.gov newsletter by email, and I am worried that I may have fraud on my Medicare.gov account. I received my current Medicare summary by mail with a Medicare claim from a medical office that I am not aware of visiting. I’m not sure what to say or how to appeal the claim when I reach out to Medicare.

Also, I am going to receive the new plastic Medicare card because I received a call a few weeks ago about it. But I’ve searched Medicare.gov website, only finding my current card. I did not give out my personal information when I received the call and just hung up like you say to do.

Please advise me how I should contact Medicare because it is difficult to know what’s the right thing to do when it involves a government agency. Thanks, Toni.

—Meredith from Katy, Texas

Meredith:

I am also on Medicare and I received the Medicare.gov newsletter about how Medicare fraud is exploding. The newsletter stated, “Check your Medicare statement for charges you don’t recognize.” It warned against scammers trying to con those on Medicare out of their information and money.

Below are three tips the newsletter presented to protect everyone from scams:

1. If you get a call, text or email asking for your Medicare Number, don’t respond. NEVER give your Medicare card or number to anyone except your medical provider/facility or anyone you know should have it.
2. Check your Medicare Summary Notices (MSNs) or claims statements carefully for possible fraud. Meredith, this is your Medicare situation, because you see a charge for a service you don’t remember getting. To appeal this medical claim, contact Medicare at 1-800-Medicare (1-800-633-4227).
3. Guard your Medicare card. It is like your Social Security card or a credit card. Treat your Medicare card like it is gold!

Finally, Meredith … guess what? There is no new plastic Medicare card like a credit card. This is another scam that is targeting America’s Medicare population. Your Medicare card is still the same card you currently have.

Again, if you suspect that you are experiencing Medicare fraud, call and report your issue to Medicare at 1-800-Medicare (1-800-633-4227).  Explain to the Medicare agent what has happened and have your Medicare corrected ASAP.

Medicare and Social Security will never randomly call your home or office and ask for your personal or banking information. Medicare already has all the information they need about you.  If information were needed, a letter would be sent advising you what a specific government agency such as Medicare needs and to contact them for additional information.

Medicare fraud is estimated to cost more than $60 billion a year. Fraud hurts America because when thieves steal from Medicare, there is less money available for health care that one really needs.

Let your friends know what I have just told you about fraud. We need to stand together and stop those who only want to make a “fast dollar” from Medicare, your checking account/credit card and most of all from you!

With Medicare…What you don’t know WILL hurt you!! For more Medicare information, email info@tonisays.com or call 832-519-8664. Both of Toni’s books and her new “Confused about Medicare” online course and Toni Says Medicare Roadmap are available at www.tonisays.com.

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Hi Toni:

Turning 65 in May and having an issue trying to enroll in Medicare since my Social Security account is locked.  Two years ago, someone falsely filed a tax refund with my Social Security number. Now anything that involves me or my spouse’s Social Security number, credit report or IRS information is locked and cannot be accessed.

How I can enroll in Medicare when I cannot open up a “My Social Security” account? This is what the Medicare.gov website advises me to do since I am turning 65 and not on employer’s benefits. I am a self-employed real estate agent with an individual plan. Thanks, Toni, looking forward to your advice.

–Terri from Las Vegas, Nev.

Great question, Terri:

Americans who are turning 65 and not receiving a Social Security check, should apply for Medicare by visiting www.ssa.gov/medicare/sign-up 3 months prior to turning 65 for Medicare Parts A and  B to begin the first day of the month turning 65. This information is available on page 17 of the 2026 Medicare & You handbook.

A fraud situation with your Social Security number like you are experiencing, Terri, with your Social Security situation can prevent anyone from opening a “My Social Security Account.” Terri, both you and your spouse’s Social Security numbers and accounts are locked by both Social Security and the IRS, keeping you and your husband (if married) from applying for Medicare online.

Anyone who is locked out of their Social Security account due to fraud, the quickest way to enroll is to visit in person at the closest local Social Security office. You can find your specific Social Security office by searching online with your zip code. This office can unlock your Social Security numbers allowing both you and your spouse to open a “My Social Security” account and can enroll you in Medicare online to begin the first day of the month you turn 65.

Terri, I would advise you and your spouse to not leave that local Social Security office until your “My Social Security” accounts have been either re-opened or new accounts have been created, and your Medicare enrollment is finalized.

Those turning 65 who need to enroll in Medicare and do not have a locked Social Security account, may go online to www.ssa.gov/medicare/sign-up to enroll in Medicare

If you do have a “My Social Security Account”:

• Have your username and password handy to begin Medicare enrollment.

If you don’t have a “My Social Security Account”:

• Open a “My Social Security Account” at ssa.gov/myaccount to be prepared to apply for Medicare Parts A and B, when turning 65 and not working full-time with employer health insurance or covered by a spouse’s employer health insurance.

Below are options to apply for Medicare when turning 65: Chapter 1 of Toni’s Medicare Survival Guide Advanced edition at www.tonisays.com explains ways to enroll in Medicare.

• Turning 65 and Receiving your Social Security check: You should receive your “Welcome to Medicare” kit by mail with your new Medicare card prior to turning 65.
• Turning 65 and NOT Receiving your Social Security check: (this is Terri’s situation)

You do not get an automatic “Welcome to Medicare” kit with your Medicare card.

You must visit ssa.gov/medicare/sign-up to enroll in Medicare for your Medicare to begin the first day of the month, you turn 65.

• Turning 65 and still working with employer’s benefits: Social Security and Medicare allow you to delay your enrollment in Medicare if you and/or your spouse are working full-time with employer benefits (not retirement benefits).

The new Toni Says Medicare Roadmap is available by signing up for the Toni Says Medicare Newsletter available at www.tonisays.com. Contact the Toni Says Medicare team at 832/519-8664 or email info@tonisays.com regarding your Medicare options. Both of Toni’s books Medicare Survival Guide and the Maze of Medicare and her new “Confused about Medicare” online course are available at www.tonisays.com.

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Toni:
When I first enrolled in Medicare in 2019, I picked Medicare supplement Plan F. In February of 2024 I was approached by a telemarketer on my cell phone who talked me into a Medicare Supplement Plan K because this plan had a lower premium than Plan F.  I could change because I was in good health at that time.

March of 2025, I was hospitalized due to cardiac issues because I passed out in the doctor’s office. Now I am having serious heart problems, causing me to need a heart transplant.

Since I have Plan K, I must pay the deductible plus 50% cost until I meet the Medicare Supplement’s maximum out of pocket and for 2026 the cost has exploded to $8,000.  I tried to go back to Plan F, but the agent said I couldn’t because of my heart issue.

I thought with Medicare preexisting conditions did not count. Can you help me to understand this? Your help would be appreciated. Thanks, Toni.

— Jason, Lubbock, Texas

Jason:

What a great question! Americans without health issues need to realize that a health care crisis can happen when you least expect it! And you must answer health underwriting questions to qualify for a new Medicare Supplement.

Jason, you went from the top-of-the-line Medicare Supplement Plan F, where you would have zero out-of-pocket and all Medicare eligible expenses would be covered 100%, to a Plan K with an out-of-pocket of $7220 for covered Medicare expenses for 2025 that has risen to $8,000 for 2026. Because you need to have a heart transplant; qualifying for a new Medicare Supplement is not an option since you cannot pass the health underwriting.

The only thing you can do is to remain on your Medicare Plan K or go with a Medicare Advantage HMO or PPO plan, because it has no health questions. Jason, you can enroll in a Medicare Advantage plan until March 31 since now is the Medicare Advantage Open Enrollment Period.  Wait to enroll after April 1 and then Medicare’s Open Enrollment Period starting October 15-December 7^th  will be the only option for you to change to is a Medicare Advantage Plan because it has no health questions.

I would recommend that you talk with your health care providers about which Medicare Advantage Plan meets their requirements. There are 2 chapters in my Medicare Survival Guide Advanced Edition that explain the difference in Medicare Supplements and  Medicare Advantage  Plans. In chapter 6, I explain what  Medicare Advantage plans (Part C) are and the different type of plans…HMO, PPO, PFFS (Private Fee for Service), SNP (Special Needs Plans). In chapter 8, I discuss Medicare Supplements, also known as Medigap policies.

With a Medicare Supplement, the most comprehensive plans covering  your Medicare expenses are Plan F, Plan G and Plan N.

• Medicare Supplement plan F covers comprehensive coverage for Medicare approved amounts with zero out of your pocket, but one must have enrolled in Medicare Part A prior to January 1, 2020, to enroll in Plan F.
• Medicare Supplement Plan G is like Plan “F” and is available to Medicare beneficiaries whose Medicare Part A starts after January 1, 2020. The difference in Plan F and G is that Plan G does not include the Part B deductible of $283 for 2026.
• Medicare Supplement Plan N has lower premiums with higher out-of-pocket costs.  There is a $20 co-pay for a doctor’s visit and a $50 co-pay for the emergency room with the Part B deductible not covered. and, in addition, Part B excess charges are not paid for by the insurance company (which Plan G covers).

Take time to discover which Medicare option is right for you. For more Medicare information, email info@tonisays.com or call 832-519-8664. Both of Toni’s books and her new “Confused about Medicare” online course and Toni Says Medicare Roadmap are available at www.tonisays.com.  Sign up for the Toni Says newsletter on the Toni Says website to keep up Medicare changes.

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Dear Toni:
My husband, Jason, is a retired veteran and never enrolled in Medicare because he uses the VA for his medical care and does not have to pay the Medicare premium. He is having heart issues and wants to go to a local cardiologist. The doctor’s office advised that he enroll in Medicare since this office will not bill the VA facility and is not in the VA’s Community Care program.

Social Security told him that he must pay more to enroll in Medicare Part B since he never enrolled when he turned 65 about 10 years ago in 2016.

After reading your Medicare articles in our local newspaper, we need your guidance. Is there a way that he can take Part B without having to pay the extra penalty? Thank you, Toni.

—Marsha from Lake Charles, La.

Hello Marsha:

Since Jason did not enroll in Medicare when he first turned 65 and is no longer working with full employer benefits, I’m afraid he will receive the Part B late enrollment penalty when he enrolls in Medicare Part B during Medicare’s General Enrollment Period from Jan. 1 to March 31. No one ever knows when they will need to receive health care outside of a Veterans Administration Center.

Now is the time for him to enroll in both parts of Medicare, Part A and Part B. He did not enroll in Part B when he was first eligible in 2016, and his “late enrollment” penalty is 10% for each 12-month period that he could have had Part B but did not sign up for it. His penalty will be for 10 full years, or an extra 120% each month for the rest of his Medicare life.

For 2026, Jason’s Medicare Part B penalty will be 120% times $202.90, or an extra $243.48, plus the Part B premium of $202.90, which totals $446.38 per month. (Chapter 1 of the Medicare Survival Guide Advanced edition explains the rules of enrolling in Medicare the right way, especially for those with Veterans’ benefits.)

If he decides to enroll in Medicare Parts A and B for the first time during the 2026 Medicare General Enrollment Period, which will end on March 31, the following Medicare enrollment rules will apply:

—Medicare Supplement Insurance: There is a six-month open enrollment period beginning the first month you’re enrolled in Part B during which the Medicare enrollee will not have to answer health questions for underwriting. After six months, complete underwriting is required.

—Medicare Advantage Plan: You can get a Medicare Advantage Plan that comes with or without prescription drug coverage. With a Medicare Advantage plan there are no health questions, but you may have to pay more. You must have both Part A and Part B to join a Medicare Advantage Plan. Coverage starts the first day of the month after you sign up.
—Medicare Drug Coverage through a Part D Plan: Medicare considers the VA “creditable” coverage,” so there is a happy ending for Jason in this regard: NOT enrolling in a Medicare Part D Prescription Drug plan with a Medicare Supplement or a Medicare Advantage HMO/PPO  is a good possibility. If Veterans with VA benefits do enroll in Part D later, they will not receive the Medicare Part D late enrollment penalty since the VA prescription drug plan is creditable. Veterans are able to keep using the VA for prescriptions.

Marsha, I would recommend to Jason that, if the Medicare premium with penalty is too high, he   remain with the VA medical facility for his care and not pay the Medicare premium. Begin exploring the non-VA medical care options by contacting the local VA facility and asking for referrals that accept VA benefits outside the local VA medical area.

Remember, with Medicare, what you don’t know WILL hurt you! For more Medicare information, email info@tonisays.com or call 832-519-8664. Both of Toni’s books and her new

“Confused about Medicare” online course and Toni Says Medicare Roadmap are available at www.tonisays.com.  Sign up for the Toni Says newsletter on the Toni Says website to keep up Medicare changes.

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Dear Toni:

I retired from my employer in July when I turned 67 and enrolled in COBRA, which began August 1, instead of enrolling in Medicare. I was told that COBRA protected me from the Medicare penalty for 18 months.

My sister showed me a topic about Medicare’s Special Enrollment Period in her 2026 Medicare & You Handbook that explained how to enroll in Medicare when leaving your employer with health benefits. The handbook states that there is an 8-month (not 18-month period) to enroll in Medicare when leaving your employer The handbook further states that COBRA doesn’t count  as current employer coverage for the Special Enrollment Period. Now I am discovering that COBRA is not a Medicare plan at all.

Have I missed my time to enroll in Medicare without receiving a penalty? Am I not even able to enroll at all. Can you explain what I should do?  I need Miss Medicare’s help! Thanks, Toni.

Eddie from Nashville, Tenn.

Hello Eddie:

You are lucky that your sister showed you what is on page 17-19 of the Medicare handbook because you are almost at the end of your  8-month Special Enrollment Period(SEP) to apply for Medicare.  Your 8-month period began August 1 and will end March 31.

Page 17 of the handbook under “Special Enrollment Period” explains the Medicare rule when you are no longer employed full-time with employer health benefits. COBRA is generally an 18-month plan for those retiring and leaving employer benefits. Page 18 of the handbook notes that, whether or not you choose COBRA, you have 8 months to sign up for Part B without a late enrollment penalty.  Waiting longer than 8 months will cause a Medicare Part B penalty for as long as you have Part B.

Eddie, enroll before your 8-month SEP window is over on March 31. After April 1,your Medicare can be denied since you waited past your 8-month window, and you will have to wait until next year’s Medicare General Enrollment Period (GEP) which is from January1-March 31. The GEP time period is the only time one can enroll in Medicare when one has waited too long and will receive the “infamous” Part B penalty.

Since you are past 65, then there are Social Security forms that your employer must provide stating that you have been enrolled in employer benefits since turning 65

Below is the information on how to enroll in Medicare past 65 and working with employer health benefits to not receive a Part B penalty:

• Download 2 forms: CMS-L564 (Request for Employment Information) and CMS- 40B (Application for Enrollment in Medicare-Part B) from gov/forms. It is vital that Eddie email or take the CMS-L564 form (Request for Employment Information) to his employer’s human resources department to sign off on the form.  Then attach the signed CMS-L564 to CMS- 40B (Application for Enrolling in Medicare Part B) which is filled out and states that Eddie wants his Medicare Part B to begin April 1.
• Before filing both forms with the local Social Security office remember to write “Special Enrollment Period”(SEP) at the top of each form for the Social Security agent finalizing the enrollment knows this filing is during a SEP time and not Medicare General Enrollment Period (GEP) to not receive a Part B penalty.
• File forms with the local SS office before April1 or before the 8-month window will expire.  (Eddie’s SEP ends March31.) Make copies of every document given and received from the SS office and  ask for the name of the SS agent you give the forms to.

Don’t forget!! With Medicare…What you don’t know WILL hurt you!! For more Medicare information, email info@tonisays.com or call 832-519-8664. Both of Toni’s books and her new “Confused about Medicare” online course and Toni Says Medicare Roadmap are available at www.tonisays.com.

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If you have been told to enroll in “traditional Medicare,” that usually means Original Medicare. Original Medicare is the federal Medicare program made up of Part A and Part B. It is not the same as a Medicare Advantage plan. With Original Medicare, there is generally no plan network like many employer plans or HMOs, as long as the doctor or provider accepts Medicare. Medicare itself uses the term “Original Medicare,” not “traditional Medicare.”

A reader recently asked:

Good morning, Toni,

I have been reading your Medicare column, and now I need your Medicare help.  I am retiring when I turn 65 in April.  I was hospitalized in November of 2025 with a triple bypass surgery. Last week I talked with the office manager at my cardiologist’s office about enrolling in Medicare and what I should do.  She said for me to enroll in “Traditional” Medicare.

I have no idea what “Traditional” Medicare is? Could you please explain what this is and make it easy to understand?  I do not want to enroll in the wrong Medicare plan and have any issues having my medical bills paid.  Thank you, Toni.

– Sean from Chattanooga, Tenn

That is a smart question, especially when you are getting ready to retire and want to make sure your doctors and hospital bills are covered correctly.

Traditional Medicare vs. Original Medicare

Many doctors’ offices and insurance agents casually say traditional Medicare, but Medicare’s official name for it is Original Medicare. In fact, you will not find the phrase “traditional Medicare” anywhere on the Medicare.gov website or in the Medicare & You handbook. Original Medicare includes only:

• Medicare Part A for hospital insurance

• Medicare Part B for medical insurance

It does not include:

• Part C, which is Medicare Advantage

• Part D, which is prescription drug coverage

• Medigap, which is supplemental coverage sold by private insurers

So when someone says “traditional Medicare,” they usually mean Original Medicare Parts A and B.

What does Original Medicare cover?

Medicare Part A

Part A helps cover:

• inpatient hospital stays

• skilled nursing facility care after a qualifying hospital stay

• hospice care

• some home health care

For 2026, the Part A inpatient hospital deductible is $1,736 per benefit period. For skilled nursing facility care, the daily coinsurance is $0 for days 1–20 and $217 per day for days 21–100.

Medicare Part B

Part B helps cover medically necessary outpatient and physician services, including:

• doctor visits

• outpatient surgery

• lab work and diagnostic testing

• durable medical equipment

• outpatient hospital services

• preventive services and other medical care

For 2026, the standard Part B premium is $202.90 per month for beneficiaries with income below the applicable IRMAA thresholds, and the Part B deductible is $283 for the year. Higher-income beneficiaries may pay more for Part B.

After you meet the Part B deductible, Medicare generally pays 80% of the Medicare-approved amount, and you pay 20%.

Does Original Medicare have a network?

One of the biggest differences between Original Medicare and many employer or private insurance plans is that Original Medicare does not work through a typical HMO or PPO network.

That is why many people find it confusing at first.

If a doctor, hospital, or provider accepts Medicare or accepts Medicare assignment, they can generally treat you under Original Medicare. That broad provider access is one reason some doctors’ offices prefer patients to stay with Original Medicare rather than join a Medicare Advantage plan.

Why might a doctor’s office recommend Original Medicare?

A provider’s office may suggest Original Medicare because:

• it is widely accepted

• it usually gives patients more provider flexibility

• referrals are generally less restrictive than many HMO-style plans

• billing can be more straightforward when the provider accepts Medicare

That does not mean Original Medicare is always the best fit for every person. It just means your provider may be more comfortable working with that coverage model.

How do you pay what Medicare does not cover?

This is where many people get caught off guard. Original Medicare does not cap all of your out-of-pocket costs on its own. You still may owe deductibles, copays, and coinsurance. That is why many people pair Original Medicare with:

Medigap

A Medicare Supplement insurance policy, also called Medigap, helps pay some of the out-of-pocket costs that Original Medicare leaves behind. Medigap works with Original Medicare, not with Medicare Advantage. CMS notes that Medigap plans are designed to help with costs like deductibles, copayments, and coinsurance.

Part D

If you choose Original Medicare, you may also want a stand-alone Part D prescription drug plan for medication coverage.

Is Traditional Medicare the same as Medicare Advantage?

No. Traditional, or Original Medicare, is not the same as Medicare Advantage.

Original Medicare

• run by the federal government

• includes Part A and Part B

• no typical HMO/PPO network structure

• can be paired with Medigap

• can be paired with a stand-alone Part D plan

Medicare Advantage

• offered by private insurance companies approved by Medicare

• often includes provider networks

• may include drug coverage

• cannot be paired with Medigap in the same way as Original Medicare

So if your doctor’s office told you to choose “traditional Medicare,” they were likely telling you to enroll in Original Medicare, not a Medicare Advantage plan.

Here’s my full answer to the reader question:

Hello Sean,

Don’t worry, Sean, I will make this easy for you. Let’s examine just what “Traditional” Medicare is.

Most health care professionals and office personnel call Medicare, “Traditional” Medicare, but Medicare refers to the federal health program as “Original” Medicare. You will not find “Traditional” Medicare anywhere in the Medicare.gov website or in the Medicare & You handbook.

Original or Traditional Medicare consists of only Medicare Parts A (Hospital Insurance) and B (Medicare) and not the rest of the alphabet soup such as Parts C or D. Original/Traditional Medicare is also known as your Medicare card.

There is not a network with “Original/Traditional” Medicare, and this is hard for those who have retired with employer group health insurance to understand, “NO Network”! If your hospital, doctor, or health care provider accepts “Original” Medicare or Medicare assignment, then they will accept “Traditional” Medicare because “Original/Traditional Medicare are the exact same program.

So Sean, you want to know about Original or Traditional Medicare. Let’s first discuss Medicare Parts A and B: Medicare began July 30, 1965, when President Lyndon Johnson flew to Independence Missouri to sign Medicare into law in front of President Harry Truman who had originally tried to pass Medicare as a federal program for America.

MEDICARE PART A (Hospital Insurance) is for an in-patient hospital stay. Part A deductible for 2026 is $1,736 and has 6 deductibles in a year.  Yes, Part A has a benefit period of 60 days, so every 60 days there is a new deductible.  Skilled nursing has a $0 co pay for days 1-20, but there is $217 co pay per day from days 21 through 100.  After day 100 in a skilled nursing facility, you pay the full cost. Medicare Part A also includes hospice and home health care with a $0 co pay.

MEDICARE PART B (Medical Insurance) has a premium of $202.90 which is based on income. The more you make the more you pay. Americans with income levels under $109,000 for an individual or $218,000 for a couple will pay the $202.90.  The more you make, the higher your premium will be. The 2026 Medicare Part B deductible is a yearly one-time deductible payment of $283.

• Medicare Part B covers “medically necessary” services such as office visits, surgery, hospital stays, outpatient hospital care/services, tests, durable medical equipment, and other medical services.
• Medicare pays 80% of the Medicare approved amount and you pay 20% of the Medicare approved amount.  For example, a medical provider may charge $1,000 for a service, but Medicare may approve $623. It is the $623.00 that the 20% is applied to.

Sean, you may be wondering how you pay for the out-of-pocket that Medicare Parts A and B have.  Your option would be a Medicare Supplement/ Medigap policy that works only with Original/Traditional Medicare and does have a monthly premium based on which Medicare Supplement plan is selected. FYI:  A Medicare Advantage Plan Part C (HMO/PPO)plan is not associated with Original/Traditional Medicare but with private health insurance companies and is not what your doctor’s office has advised you to use.

More Medicare Help

For answers to your Medicare and Social Security questions, call the Toni Says Medicare team at 832-519-8664 or email info@tonisays.com. 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.

Sign up for the Toni Says newsletter to keep up to date on Medicare changes.

The post Doctor’s Advice…Enroll in Traditional Medicare…What is that? appeared first on ToniSays.

Toni:
On November 6, when the government was still shut down, I turned in my Medicare enrollment forms signed by my employer to the local Social Security office. I never received anything from Social Security about being enrolled, so I went to the office and found out that my paperwork was lost. I refiled a copy of the forms with Social Security about 3 weeks ago and now my Social Security fun begins.

Now, I must fight Social Security because they are under the impression that I have waited past my 8-month window to enroll in Medicare Part B, which I did not. I am now receiving a Part B penalty. What a nightmare!

I remember reading a Toni Says Medicare article about asking a local Congressional office for help with Social Security or governmental issues. Can you please explain what one should do to get help from your congressperson in appealing an inaccurate decision about Medicare from a local Social Security office/agent? Thanks, Toni.
–Nick from San Antonio, Texas

Hello Nick:
If you need help with your Social Security and Medicare issues, then talk with your area’s congressional office. Your congressional office is the one to help you solve your issues with a federal rather than state government organization such as Social Security, Medicare, IRS, VA, or other federal programs. Visit your congressperson’s website for the local office contact information or you can email that office your issue from the Congressional website.

Page 17 of the 2026 Medicare & You Handbook under “Special Enrollment Period” explains the rules of leaving employer’s benefits when you are “still working” past 65. It discusses the special 8-month window for enrolling in Medicare and spells out that the 8-month period begins the month after the employment ends or health coverage ends, whichever happens first. Nick, when you enrolled with Social Security, you might have been close to the end of the 8-month window so let’s explain this to your congressional office’s agent when you contact them.

Below are a few of the Social Security forms used for Medicare: Don’t forget to write “Special Enrollment Period” to keep from receiving a penalty at the top of these specific forms (CMS-L546, CMS-40-B and SSA-44) , when turning the forms into the local Social Security office in your area or by email.

• CMS-L564 – “Request for Employer Benefits” is the form that shows proof of employer health benefits from the specific employer. If you have had 2 or more employers since turning 65, have a CMS-L564 form signed by each employer to turn into Social Security when applying for Medicare Part B(medical insurance).
•  CMS-40B – “Application for Enrollment in Medicare Part B” is the application for enrolling in Medicare Part B (medical insurance) Attach this form with the CMS-L564- (Request for Employer Benefits) when applying for Part B after leaving employer benefits past 65 and 90 days.
• SSA-44- “Medicare Income-Related Monthly Adjusted Amount – Life-Changing Event” advises Social Security of a major life-changing event that has lowered your income. Life-changing events include marriage, divorce, the death of a spouse, work stoppage or reduced hours, lost, lost property, and more options listed on the SSA-44 form.

Nick, you should search for documents and evidence you have to prove that you did not wait past the 8-month window to apply for Medicare after leaving employer benefits. Have them ready to show or send to a representative from your congress person’s or local Social Security office.

Readers, remember to always have Part B in place when leaving your job or losing your company benefits. There might not be a second chance! Call the Toni Says® office at 832/519-8664 to schedule a Medicare review or email info@tonisays.com. 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. Sign up for the Toni Says newsletter at www.tonisays.com to keep up to date on Medicare changes.

The post Help! Who do I contact with a serious Medicare enrollment issue? appeared first on ToniSays.