Hi Everyone, and welcome to the Wiser Financial Advisor with Josh Nelson, where we get real, we get honest, and we get clear about the financial world and your money. This is Josh Nelson, Certified Financial Planner and founder and CEO of Keystone Financial Services. Let the financial fun begin!

Josh: I’ve got a special guest today, Dana Griffin from Choice City Health, talking about Medicare. Welcome, Dana.

Dana: Thanks, Josh.

Josh: This is a timely topic because Medicare open enrollment comes up pretty soon. When’s the date?

Dana: It comes up from October 15th to December 7th of each year. If you are anywhere approaching Medicare and you’re paying attention, you’re going to see ads, phone calls, solicitations all over the news and the media these days.

Josh: Clients that are approaching Medicare age, or even after they’re eligible, get bombarded with stuff in their mailbox and emails and unsolicited calls, things like that.

Dana: You think you have a handle on it, and then all of a sudden, one of your friends or neighbors or something in the mail creates a question. And then everybody has an opinion on Medicare, so let’s see if we can clear up some of those confusing items for folks and get them on the right track.

Josh: Today, our discussion is going to focus more on Medicare for sure, but we will touch on what if you’re not Medicare eligible yet? What other health options do you have? We’ll talk about some resources. When we talk to our clients, we’re a fiduciary and financial planner, so we’re having conversations not just about investments, but also overall financial plans. And of course, healthcare is a huge part of that planning, not just today, but how people will be impacted in the future. We’ve got a couple of different groups here listening, and probably one of the biggest groups would be people that are approaching Medicare age and starting to get bombarded. They’re trying to educate themselves. So, when should they start thinking about this? When’s the best timing to start doing some planning around coverage and understanding some of these options?

Dana: That’s a great question, Josh. I think age 63 is when people are starting to think about Medicare. This is a federal program. It came out in 1965, and the rules today say you’re not eligible for Medicare until age 65. The soonest you can typically sign up is 3 months before the month of your birthday in the year you turn 65. And if people want to plan ahead, we’d say age 63, 64. At that point, you want to be aware of how much Medicare is going to cost and asking things like, “What is my group plan or my employment situation looking like? Will I be able to work past 65?” Especially if you have a spouse that might be younger or you have kids still on your plan, I think 63 is a good place to start.

Josh: Good. How about a little 101 for those of us who aren’t experts like you. What does it mean when people talk about Part A, Part B, Part D, all these different parts?

Dana: So, Medicare is this federal program and it starts with original Medicare, which is your Part A hospital coverage. Your Part B is your medical. Part A is what we’re paying into during our working years, and it’s withheld from our taxes. Generally, when you turn 65 you’re going to have what we call premium-free part A. It’s already been paid for. Then you have to decide when you approach 65 whether you want to get part B. And if you’re not working or you’re not covered under an employer plan, the rule of thumb is yes, you need to go and get part B, even folks that might have VA or TRICARE, serving in our military. Part B has different premium levels. The standard premium is about $185 a month currently. Last year it was $174 and some change. We anticipate for 2026 that Part B will be anywhere from $195 to a little over $200 a month. Part B is your original Medicare, and it’s a great foundation. It gives you national coverage for any doctor or hospital in the country. So for a lot of people who’ve felt like they’ve been paying more and getting less in healthcare, Medicare is something to look forward to. It’s something that drew me into Medicare in the beginning. It’s a federal benefit that gives you a lot of flexibility and peace of mind.

Once you have your original Medicare, you can build on it because Medicare is not going to cover everything. It’s a place to start. You have the option of sticking with original Medicare or going into something called Part C, and that’s Medicare Advantage. We now have over 60 million people on Medicare across the country, and over half those people have chosen a Part C plan. It has its place and it’s worth taking a look at, but it’s not for everybody. Basically you’re assigning your Medicare benefits to a private insurance company, and they have a contract with Medicare, and they have to renew that contract year to year. With that, you pick up extra benefits you might not have covered under original Medicare. There might be something that’s important to you, like a gym membership, or some dental coverage, things like that. The nice thing about Medicare Advantage is you can shop that every year during that annual enrollment period I mentioned—from October 15th to December 7th.

Having an agent to guide you could be helpful when choosing a plan because there are a lot of pitfalls or things to be aware of when you get on Medicare Advantage. You want to make sure your doctors are covered. And it goes beyond networks. But if you want to get out of Medicare Advantage, how do you do so, and what are some of the considerations? It’s easy to get into Medicare Advantage once you have Medicare, but getting out of it may be a different story.

Josh: Sure. So an advantage of Medicare Advantage is the fact that you may have 0 premiums, right? You’re not paying anything beyond your Part B. It may be appropriate for somebody who basically just does their annual checkup and doesn’t really access a lot of services. But I mean, if let’s say the situation changes and you are using a lot of services, talk about that. How can you switch back or get out of it? Or why is that an issue for people?

Dana: Well, we think we’re on a federal coverage and we have the Affordable Care Act in place and pre-existing conditions shouldn’t matter. But in the world of Medicare, when they passed the Affordable Care Act back in 2013, it was not targeting Medicare at all. So, there is still medical underwriting for the other side. In addition to A and B, your original Medicare, you have your private Part C coverage, which is comprehensive. They have the contract with Medicare. It’s going to cover the same level of benefits you would have under only hospital Part A plus medical Part B, and they’ll often include your drug coverage, Part D, which we’ll get into n a minute. But with your Part C plan, if something changed in your health, you could be facing co-pays up towards what we call a maximum out of pocket. Those maximums can vary from $4,400 all the way up to $6,700 or beyond. That can get expensive if you’re in a situation with a chronic illness or you’re going through a lot of changes. But like you said, if you’re healthy and all you need is your annual physical and a few things like that, Medicare Advantage is a good place to start.

I do like the fact there’s competition in the Medicare Advantage space, with all these companies trying to one up each other. It works well for a lot of people to have a choice of benefits. But then things can change. Right now, one of our preferred carriers just got a notice from UC Health, the big hospital system here in our state, that they’re going to be out of network. So, there’s always room for disruption because it’s healthcare. And once you get on Medicare, you want to set it and forget it, but it’s hard to do with Medicare Advantage. It’s not necessarily a set it and forget it type of product.

Josh: Yeah, so there is a way out, in other words, but it’s hard to do.

Dana: Usually, I mean, if things are going well with you in your health, you don’t want out because you’re saving money. Let’s talk long-term strategy. If you’re not on Medicare Advantage, you’re going to be on original Medicare and you want to fill in those gaps with a Medicare supplement, also known as a Medigap plan, which has an extra premium beyond Part B. But those plans increase their premiums as you get older, and could be upwards of $250, $350, almost $400 a month. You start off with that Medigap plan and pay the extra premium because it checks a lot of boxes. I can go to any doctor or hospital I want. I have control over my healthcare expenses. But then those premiums go up over time. In the last few years, we’ve had double-digit rate increases. So as you get older, into your 70s or 80s, you’re getting squeezed out of Medicare supplements because of the high cost of premiums, and you’re forced into Medicare Advantage just for the cost. But that might be when you need the protection of a Medicare supplement the most. So there are things we can do.

In our agency, we like to spend time helping people understand the pros and cons, develop the roadmap or strategy to help you think about what’s ahead instead of just what’s right in front of you this year, and what would be a good fit for you long term.

Josh: It’s very situational. I mean, we do find a lot of that, where people just ask their friend or their brother or whoever and then copy that person, but that doesn’t really make sense. Their situation is going to be different.

Dana: You know, we had something like that yesterday. I got a referral from a client. A brother has a problem where he has too much money in retirement, if there is such a thing. But his sister needs help and she’s on Medicaid and we’re trying to assist her. So everyone is very situational. What works for one person may not be the same for you. We talked about part A, part B, that’s your original Medicare, your foundation, let’s say. Then you have part C, your advantage. And the newest part is the drug coverage called part D that came out in 2006. And that’s where you pick up your prescriptions.

There are two ways to get prescriptions in the world of Medicare. It’s either through Part D as drug coverage, or B as in boy, that’s your medical. So when we think about peace of mind and having our healthcare there for us when we need it most, you want to make sure you’re covered for things like chemotherapy infusion medications. Those are the expensive ones, and those are covered under Part B. Part B without a supplement means you pay 20% coinsurance. So the reason you want to have coverage other than just original Medicare is because you don’t want to get stuck with 20% of some big bill.

Part D is the newest form of coverage, and that is just going through a major overhaul here in 2025 as a result of the Inflation Reduction Act, which came out in 2022, and it included this aspect of Medicare Part D coverage. Before this Inflation Reduction Act, your exposure to drug costs was much higher. It was $8,000 or more per calendar year. The Inflation Reduction Act got rid of something called a donut hole or coverage gap, where if you spent over a certain threshold on prescriptions, you got stuck in this gap stage and had a lot more out of pocket. The Inflation Reduction Act wiped that off, but in my opinion they didn’t take into account anything from the insurance industry and the drug companies that were administering these plans. So they got rid of the coverage gap, and then they decided that we’re going to have the insurance companies pay for this instead of Medicare. It used to be that Medicare paid for 80% of the cost after what we call the last stage, the catastrophic stage after $8,000. So, they brought that last stage maximum out of pocket for the consumer down to $2,000. There are lots of aspects to this. The consumer now benefits from a $2,000 max out of pocket, but they shifted the burden up to 60% onto the Part D carriers or providers. Last year when this came out and it was scheduled to go into play for January 1, it was an election year, and they introduced this thing called a demonstration project to allow these insurance companies to smooth out and soften their rate hikes, because now they have this $2,000 cap they have to start paying for.

Big picture, there’s a lot going on with drug coverage, but for those people that might be working past 65 and they’re happy with their work plan, I encourage them to pay attention to this open enrollment from their employer because they will get notices if their plan meets the guidelines of credible coverage or not. What we’ve seen overall is even from employer plans or ACA individual plans, you might have a max out of pocket of $5,000, $6,000 or beyond, or maybe you have a health savings account and you’re happy with that plan. But now the rules are that your plan may not be good enough in the eyes of the government because it has a higher out of pocket than $2,000.

Josh: And there are some timing topics there too, right, because we’re seeing more and more people choosing to work or maybe having to work past age 65. So how does that typically work? In other words, do employers tend to let people stay on their group coverage? Do they kick them off? Do they make them sign up for Medicare? What do you tend to see?

Dana: If your employer has less than 20 employees, you work for a small employer or you’re self-employed, you need to get into Medicare when you turn 65 because Medicare is your primary coverage. Okay, so we’ll leave that as a talking point. But for those approaching age 63 who plan on working, you’re going to want to start paying attention because of this change in the Part D rules, so if your plan at work is either an HSA or has a fairly high deductible, every year you’ll get a notice. We’re anticipating up to 90% of plans won’t qualify. CMS (Centers for Medicare and Medicaid Services) gave everybody a pass the first year, but now they’re going to use actuarial values to evaluate employer plans for whether or not they’re considered credible. So, if you put your head in the sand and don’t pay attention, you could get stuck with a late enrollment penalty on your drug coverage, even though you were working and you thought everything was fine. And these penalties are for life. Depending on how long you work past 65, it might be a nuisance in the beginning, but it is definitely a drag. We don’t want penalties if we can avoid them.

Josh: Yeah, that’s an important topic and one that a lot of people don’t know about, right? You do need to enroll, especially if you’re not with an employer, right? There is a time frame. So you said three months before your birthday, and how long do you have to sign up for these plans after you hit age 65 before you start being subject to those penalties?

Dana: Your initial enrollment period is what we’re referring to, and that’s the three months before the month of your birthday, the month of your birthday, and the three months following. So you have a seven-month window that you can sign up for Medicare. That really applies to those folks that are not working or have retired early or if your employer is under 20 people.

Josh: A lot of people have never heard of IRMAA (ncome-Related Monthly Adjustment Amount) and they don’t hear about it until they get a letter from Medicare. So talk about IRMAA and how does that work?

Dana: Well, often people think, “Well, I paid into Medicare and it should be free.” There are a lot of misconceptions, but when you get to Medicare Part B, they refer to it as a standard premium. That standard premium today in 2025 is $185 a month. But that’s not the true cost. The federal government is paying closer to $628 a month on your behalf. So as you go up the income ladder, there’s a threshold of about $212,000 annual income for a married filing joint or about $106,000 or so for an individual. If your income is over that, you start to pay this IRMAA which is stair-stepped. You can go to medicare.gov, or plug into your Google search IRMAA and you’ll see what that is. It can go as high as $628 a month on Medicare premiums.

Josh: Yeah, and that’s always a two-year look back on income, correct?

Dana: It’s a two-year look back. And as people are approaching those retirement age strategic decisions, their income might be under that $212,000. If they’re trying to do any kind of rollovers, getting into Roth IRAs or selling an asset, a rental property or anything like that, it could definitely throw them into IRMAA. That’s where I would encourage people to do that planning with your office and we can work together on that to help them avoid IRMAA.

Josh: For the low levels, it’s just a little bit of an increase rate that people have, but it can get pretty ugly.

Dana: You can be up to $700 a month or more in IRMAA on your Medicare premiums before you even get into Medicare supplements. So usually, we’ve worked our whole lives to get to this point, and we want to have control over healthcare. We like the idea of a Medicare supplement or Medigap, but it can get expensive.

Josh: Yeah, absolutely. And more than likely it’s going to get worse in the future, right? There’ll be some future Congress that’s trying to rescue Medicare and Social Security, all these programs that they say are trillions of dollars underfunded. More than likely, it’s my guess that they’re going to do stuff like this, right? There are definitely headwinds.

Dana: We have headwinds coming at us from different directions. And having a licensed professional guide you is probably more valuable than ever because of the complexity. I mean, you can certainly do it yourself and get signed up, but then if you make a decision, you could be stuck with that decision. It’s nice to have some guidance. We want to empower people through education that they’re making these right decisions and they’ve taken into account other factors, especially when it comes to IRMAA or pre-existing conditions. Medicare covers that hospital and doctor visit care, but it doesn’t cover everything you might need. There’s a place for long-term care planning for folks if they have a history of Alzheimer’s in their family. If they’re thinking Medicare is going to cover them, it may or may not.

Josh: That’s a good point and a whole other topic, right? Long-term care planning and so forth. Medicare doesn’t cover much when it comes to long-term care expenses, and Medicaid basically means you’re out of assets. But there’s often a misconception that Medicare has some kind of long-term care coverage so people don’t need to worry about it.

Dana: I don’t know what else I can say about those financial headwinds and Medicaid, but I think buckle up and take it one step at a time, one year at a time.

Josh: We talked about people that are approaching Medicare. We have a significant number of people that either by their choice or maybe they got a retirement package, something like that, and they’re out of their employer coverage. Also, there’s COBRA, right? You get a certain number of months, but what resources are out there to figure out what kind of coverage I should be getting?

Dana: If you just left an employer plan, COBRA is one. We definitely want to include that in the conversation because COBRA is usually the same benefits you had from work. And often it’s better coverage than what you could get on the open market. So when you go on to the open market, you can either get your coverage on the exchange, and we have a state-run exchange here in Colorado that’s called Connect for Health Colorado, or you can get it off the exchange. And that’s where you go directly to the carrier and you often would work with a broker like myself. Those plans are going to generally be identical to what you had, but they’re tied to inflation. They’re going to be in this metallic series, bronze, silver, gold. A bronze plan might have a $9,000 deductible. But if you’ve got some ongoing prescription costs and things like that, COBRA could be worth your time and worth a closer look than you might have thought otherwise.

Josh: When it comes to somebody who’s already on Medicare, these topics are still relevant because of the open enrollment, right, as we have that coming up. What are some things that people don’t know about after signing up for Medicare, things that have changed or things they need to plan for that they weren’t thinking about before?

Dana: Well, things to be aware of right now if you’re leading up to Medicare, especially if you went through the exchange we call Connect for Health, the enhanced tax credits were under something through the Biden era, so your premiums were artificially low and those are going to sunset at the end of this year. So, we don’t know how much higher premiums will go. We’re anticipating 13% on the low end but probably closer to 20, 25% premium adjustments.

Josh: Yeah, that’s going to be a surprise.

Dana: You know, it’s healthcare, unfortunately. But if you’re COBRA and Medicare, you want to be careful there. Just because you have COBRA isn’t necessarily considered credible coverage in the eyes of Medicare. If you’re eligible for Medicare, you don’t necessarily want to hang out in COBRA for too long.

Josh: Yeah, get with somebody like you. I mean, this is all you do, right? You’re an expert. Here at Keystone, we’re CFPs, Certified Financial Planners, which means we know a lot, but there are certain areas, and this is definitely one of them, that are a specialty. You really want somebody who knows what they’re talking about and is staying up with it.

Dana: So Josh, what else do you think we could cover? I mean, there’s open enrollment for those that are not in Medicare open enrollment and going to the ACA open enrollment. So, some things we’ll do with folks who have lost their job or are anticipating retirement who may want to plan around the ACA open enrollment to get an idea of what premiums and costs will be. That’s November 1st to December 15th. There’s some overlap there with the Medicare open enrollment annual election period. We should get those new rates middle of October, but if you’re coming off an employer group plan, you could stretch COBRA for a few months so you don’t necessarily have to start over on your deductibles. And then, you know, they’re tightening up on these ACA open enrollments that used to go out further. They might have gotten rid of that January 1st to January 15th open enrollment.

Josh: Sure. Are there any other common misconceptions or pitfalls that we haven’t covered? I mean, situations you run across that would be helpful for people?

Dana: Well, if you’re on Medicare, the biggest thing is not opening something called your annual notice of change. If you have a prescription drug plan or a Medicare Advantage plan, you need to pay attention and open the mail this year. There are changes. You know, we’ve had higher utilization, and the carriers have taken cuts from Medicare. Your plan might look different. Your prescription that was covered this year may not be covered next year or it’s going to be more expensive. So we encourage people to at least do some shopping on their prescription drug coverage.

Josh: Yeah, that’s good. And this stuff changes every year, right? There are always slight rule changes every year. I think most people do think that once you enroll in Medicare, it’s set it and forget it and never have to worry about this again, but that’s not the case.

Dana: That’s not the case. For example, I had a gentleman come in yesterday. He’s on a Medigap plan, one called Plan F, because his birthday was before 1955. And we just switched him, updated his coverage and saved him $156 a month and basically kept him the same identical coverage. He’s thrilled.

Josh: I’m sure. You’ll get a Christmas card from him. There you go. Good deal. So the best way for people to find you, you’re at Choice City Health.

Dana: www.ChoiceCityHealth.com . You can give us a call at 970-407-9399. I look forward to hearing from you.

Josh: And I can tell you just from existing clients, that the people twe’ve sent your way have given very good feedback. That’s important in the financial planning process, that not only are we looking at their stuff, but also involving other experts when needed, whether attorneys, CPAs, insurance agents, people that are subject matter experts in those areas. So I appreciate the fact that we’ve gotten good feedback and the relationship with you has been good.

Dana: Well, thank you, Josh. And there’s a misconception that people will have to pay extra if they have an insurance agent. That’s not the case. Once these plans are filed, either with CMS or the Division of Insurance, there’s not really any room for markups or discounts because we’re a very regulated business. The price is the price or the premium set. So once that DOA signs off on it, you’re getting the same price if you use an agent or you do it on your own. We get paid from the carriers, but it doesn’t impact you whatsoever.

Josh: Good deal. Well, thank you so much, Dana. I appreciate your time. If anybody has questions, of course they can reach out to us as well. We’re good at navigating and helping people figure out where they should go and incorporating everything into your financial plan. Thanks for the conversation and happy open enrollment season.

We love feedback and we’d love it if you would pass it on to me directly at josh@keystonefinancial.com . Also, please stay plugged in with us, get updates on episodes, and help us promote the podcast by rating us five stars and also subscribing to us at Apple Podcasts, Spotify, or your favorite podcast service.

Keystone Financial Services and Dana Griffin are separate and non-affiliated parties. Keystone does not endorse or receive compensation from Dana Griffin. The views expressed represent the views of Dana Griffin. The views are subject to change. This material is for informational purposes only. Investment advisory services offered through Keystone Financial Services, an SEC Registered Investment Advisor.