What is the loophole in Medicare?

"Loophole" in Medicare refers to several different issues, including a major one where Veterans Affairs (VA) hospitals don't bill Medicare for care provided to veterans, allowing private Medicare Advantage insurers to collect significant payments for those members while the VA covers the costs, and another where high-income business owners can avoid Medicare taxes through certain corporate structures, potentially weakening the program's funding. Other "loopholes" involve how states can exploit Medicaid tax rules and how hospitals previously inflated Medicare payments, but the VA/Medicare Advantage issue and the tax avoidance are prominent concerns.

What are the biggest mistakes people make with Medicare?

The biggest Medicare mistakes involve missing enrollment deadlines, failing to review plans annually, underestimating total costs (premiums, deductibles, copays), not enrolling in a Part D drug plan with Original Medicare, and assuming one-size-fits-all coverage or that Medicare covers everything like long-term care. People often delay enrollment, get locked into old plans without checking for better options, or overlook financial assistance programs, leading to higher out-of-pocket expenses and penalties. 

Why are doctors dropping Medicare patients?

Physician Medicare reimbursement dropped 33% since 2000, when adjusted for inflation, according to the AMA. As a result, Ferguson said, many practices—particularly small, independent ones—can no longer afford to absorb the losses. "It's gotten to a point where you can't absorb it.

Is there any way to avoid the donut hole in Medicare?

To avoid the Medicare donut hole (coverage gap), focus on reducing drug costs by choosing generics, comparing plans annually, using mail-order or discount cards (like GoodRx), asking your doctor for samples, and enrolling in assistance programs like Extra Help if you have low income; the goal is to keep your total spending below the coverage gap threshold, though the gap's impact lessens each year, especially for generics.
 

What is the Medicaid loophole?

The inadvertent loophole currently allows some health care-related taxes, especially taxes on managed care organizations, to be imposed at higher tax rates on Medicaid taxable units than non-Medicaid taxable units, contrary to statutory and regulatory intent for health care-related taxes to be generally redistributive.

What Loopholes Help Approve A **denied Medicare Claim**? - Golden Years Health Plan

Will the donut hole go away in 2025 Medicare Part?

As of 2025, the Medicare Part D “donut hole” no longer exists – meaning there is no longer a coverage gap during which Part D enrollees face higher drug costs. The “donut hole” was eliminated thanks to provisions of the Affordable Care Act (ACA) and the Inflation Reduction Act (IRA).

What are the five things Medicare won't cover?

Original Medicare (Parts A & B) doesn't cover most dental, vision (like glasses/contacts), hearing aids, routine foot care, and long-term custodial care, plus many alternative therapies, cosmetic surgeries, and prescription drugs (without Part D). You'll need supplemental plans (like Medigap or Part C) or separate insurance for these common needs. 

Did Biden eliminate the donut hole?

Did you know that, as of January 1, 2025, there is no longer a Coverage Gap Phase for those with Part D Prescription Drug coverage? The former coverage gap, also known as the “donut hole,” was eliminated as part of the Biden Administration's Inflation Reduction Act.

What happens if I can't afford to pay for Medicare?

If you can't afford to pay your Medicare premiums and other medical costs, you may be able to get help from your state. States offer Medicare Savings Programs for people entitled to Medicare who have limited income. Some programs may pay for Medicare premiums and some pay Medicare deductibles and coinsurance.

Can I use GoodRx if I'm in the donut hole?

GoodRx can't be used in combination with Medicare, but it can be used in place of Medicare. You may want to consider using GoodRx instead of Medicare when Medicare doesn't cover your medication, when you won't reach your annual deductible, or when you're in the coverage gap phase (“donut hole”) of your Medicare plan.

What health insurance denies the most?

In 2023, roughly one third of all in-network claims made to AvMed were denied by the medical insurance company. In this year, AvMed and United HealthCare were the medical insurance companies with the highest denial rate for in-network claims in the United States, at 33 percent each.

Is it better to go on Medicare or stay on private insurance?

Neither Medicare nor private insurance is universally "better"; the best choice depends on individual needs, but Medicare often offers lower overall costs and simplicity for seniors, while private insurance excels in covering dependents and potentially offering more choice with networks/out-of-pocket caps, though at higher premiums. Medicare boasts lower admin costs and standardized coverage, but Original Medicare lacks an out-of-pocket maximum, a feature typically found in private plans and Medicare Advantage (Part C). 

How will Medicare change in 2025 for seniors?

In 2025, the biggest Medicare changes for seniors focus on Prescription Drug coverage (Part D) with a new $2,000 annual out-of-pocket cap, eliminating the "donut hole," allowing monthly payments for drug costs, and introducing price negotiations, while Medicare Advantage plans face potential benefit adjustments, and Part B premiums and deductibles will increase. Expect some MA plans to reduce extra perks to offset new drug costs, plus updates to telehealth and integrated care options. 

What does Dave Ramsey say about Medicare?

Dave Ramsey's Medicare advice centers on planning ahead, understanding enrollment periods to avoid penalties, using Health Savings Accounts (HSAs) if possible, and supplementing Original Medicare with Medigap or Medicare Advantage (Part C) to cover gaps like dental, vision, and long-term care, stressing that mistakes can be costly and recommending expert advice for personalized choices. 

What are the three words to remember for a Medicare wellness exam?

For a Medicare Wellness Exam's cognitive test, the three common words to remember are often "banana," "sunrise," and "chair," used in the Mini-Cog screening to check your memory and thinking skills; you say them immediately and then recall them after a few minutes. 

What states have the worst Medicare Advantage plans?

States often cited for weaker Medicare Advantage performance include Louisiana, Mississippi, Kentucky, West Virginia, and Florida, due to challenges with care access, provider shortages, and quality issues like higher rates of avoidable hospitalizations and inappropriate medication prescriptions, though specific rankings vary by report and focus (e.g., satisfaction vs. overall system). Other states like New York, California, Texas, and Michigan appear on lists for low member satisfaction with specific plans, not necessarily the whole state's system. 

How much money can you have in the bank when you're on Medicare?

Medicare itself doesn't have a bank account limit, but if you need help paying costs through Medicare Savings Programs (MSPs), asset limits apply (around $9,660 for individuals, $14,470 for couples in 2025) for programs like QMB, SLMB, and QI, though California eliminated asset tests for its state-run MSPs. These limits cover countable assets like savings, but your primary home and one car usually don't count. 

Does everyone have to pay $170 a month for Medicare?

If you don't get premium-free Part A, you pay up to $565 each month. If you don't buy Part A when you're first eligible for Medicare (usually when you turn 65), you might pay a penalty. Most people pay the standard Part B monthly premium amount ($202.90 in 2026).

How much will Medicare Part D cost in 2025?

For 2025, the projected average monthly Medicare Part D premium is around $46.50, a decrease from 2024, but costs vary significantly by plan, with some stand-alone plans averaging around $40 and Medicare Advantage (MA) plans with drug coverage being much lower (around $13.50 after rebates). Your actual premium depends on your chosen plan, location, income (due to IRMAA surcharges), and potential late enrollment penalties, with some people qualifying for $0 premiums through Extra Help. 

How do I lower my Medicare premium?

To lower Medicare premiums, report income drops from life events like retirement (Form SSA-44), apply for low-income help like Extra Help or Medicaid, use HSA funds for premiums, deduct premiums from taxes, switch to a cheaper Medicare Advantage or Supplement plan, or check if you qualify for Medicare Savings Programs (MSPs) through your state. 

What is the best Medicare Part D plan?

The "best" Medicare Part D plan isn't one-size-fits-all; it depends on your specific prescription drugs, preferred pharmacies, and budget, but top-rated providers for 2026 often include UnitedHealthcare (UHC) for overall value/deductibles, Humana for low premiums/costs, and Aetna for quality/generics, with providers like Cigna (HealthSpring) also scoring high on satisfaction, requiring you to use the official Medicare Plan Finder to input your drugs for personalized results. 

Does Medicare pay for a colonoscopy?

Yes, Medicare (Part B) pays for screening colonoscopies, covering 100% of costs if your doctor accepts assignment and no polyps are found, though you pay 15% if they remove tissue (making it diagnostic); frequency depends on your risk, generally every 10 years (average risk) or 24 months (high risk). 

What is the most popular Medicare supplement plan?

The most popular Medicare Supplement (Medigap) plan for new enrollees is Plan G, offering comprehensive coverage similar to the old Plan F but without covering the Medicare Part B deductible; however, Plan F remains popular for those already enrolled, while Plan N is also a top choice for lower premiums in exchange for some copays and deductibles, according to Boomer Benefits and KFF.
 

Does Medicare pay 100% of anything?

No, Original Medicare (Part A & B) does not cover 100% of costs; it typically pays about 80% after deductibles, leaving you with 20% coinsurance for many services, plus gaps like dental, vision, and most drugs, requiring you to pay out-of-pocket or get supplemental coverage like Medicare Advantage (Part C) or Medigap. Some preventive services are covered at 100%, but most care has cost-sharing.