Blog

The differences between Medicare and Medicaid

When we explain the differences between Medicare and Medicaid, we have to start with the fact that these are two very different programs.

Both programs provide an important service to the group that it serves.  Each of these programs receives funding and is run by different parts of the government.

To sum it up:

1. Medicare is a program put in place by the federal government to provide health coverage for individuals 65 and over as well as qualified individuals with disabilities.
2. Medicaid is a program that is provided by both state and federal governments for qualified individuals who have limited income and little financial means.

Medicare AEP vs. OEP

Because the Medicare enrollment periods can be so confusing, in this post we will explain the difference between Medicare AEP vs. OEP.    It is helpful to understand the different enrollment opportunities available to make any plan changes to help optimize your Medicare coverage.

Please note:  no one is required to change plans during either enrollment period.  It is purely optional.  It is however a good idea to review your plan benefits and consider all your options during AEP.

We will start with the AEP (Annual Enrollment Period):

In Medicare, these two enrollment periods have 2 different windows of time to enroll in a plan. To differentiate between the two, you need to know the dates available to make changes for each enrollment period.  The AEP runs from October 15 through December 7 each year.  During this period, Medicare enrollees have the opportunity to make many types of changes to their Medicare coverage.  These changes allowed during the AEP include:

1. Changing from one Medicare Part D (prescription drug plan) to another.
2. You can change from Original Medicare which may include enrollment in a Medicare Supplement and or a Prescription Drug Plan into a Medicare Advantage Plan.
3. If you are in Original Medicare, you may want to add a Part D (prescription Drug) plan.
4. Change from one MA/MAPD (Medicare Advantage Plan) to another.
5. Disenroll from a MA/MAPD (Medicare Advantage) Plan and enroll in Original Medicare.  This gives you the opportunity to enroll in a Supplement Plan as well as a Part D (Prescription Drug) Plan. (Medicare supplements may be subject to underwriting)

More information about AEP:

During the AEP, Medicare plan providers use the enrollment period to announce plan updates and changes to their benefits for the following year.  These changes may include plan costs, deductibles, co-pays and coinsurance amounts. The carries send out their ANOC (annual notice of change) to their beneficiaries in hopes that they can add beneficiaries and grow the strength of their plan.  Once enrollees get their ANOC, they can decide whether to keep their current plan or consider making a change.  The AEP is the best time to compare plans and make sure you are enrolled in the plan that provides the coverage options you are looking for.

AEP allows you to make several plan changes.  Keep in mind, the last plan change you make is the one you will be enrolled in.  The plan you enroll in during AEP will begin January 1st of the following year.

Now we will discuss the OEP (Open Enrollment Period):

The OEP (Open Enrollment Period) is sometimes referred to as the MAOEP or Medicare advantage Open Enrollment Period., This enrollment period runs from January 1 through March 31 each year. The OEP differs from the AEP because only members of MA/MAPD (Medicare Advantage Plans) are able to make plan changes during this enrollment period. Member cannot change Original from Original Medicare/Medicare Supplement plans or switch from one PDP plan to another. Only changes to Medicare Advantage plans is permitted.

Enrollees of Medicare Advantage plans can make the following changes:

1. Switch from one Medicare Advantage plan to another one that provides the coverage you need.
2. Dis-enroll from you current Medicare Advantage plan and enroll in Original Medicare (this may include a supplement and PDP plan).

One important difference between the AEP and OEP is that; you may make one plan change during the OEP and that is all.  OEP is also a good time to correct any MA/MAPD plan changes you made during AEP that you are not happy with.  Any changes made during OEP will go into effect the month after your application is submitted.

Be aware that once you make a plan change during OEP/MAOEP you will not be able to make changes until the next AEP.  This rule does not apply to individuals with an SEP.

Learn more about the Medicare Advantage Open Enrollment Period

Please note:

Beneficiaries of Medicare Supplement (Medigap) plans are not subject to either of these enrollment periods.  They have their own enrollment rules.

Are you a Medicare agent?  Learn why you should join the team at Crowe and Associates

Click here to view more images by this artist

Assisted Living FAQs

Because many people have questions about assisted living, we are providing answers to the most asked Assisted living FAQs in the post below.

What is an assisted living facility:

Assisted living facilities provide individuals assistance with the ADLs (activities of daily living).  These activities include; meal preparation, bathing, dressing as well as medication management to name a few.  All these activities are categorized as custodial care.

Click here to learn more about the activities of daily living

What is the difference between Medicaid and Medicare in assisted living coverage:

There are definitely difference in how Medicare and Medicaid provide coverage for assisted living.

1.  Medicare does not provide any coverage for assisted living facilities. Although it does short-term stays in a skilled nursing facility for rehabilitation purposes as long as specific requirements are met.  This criterion includes the exclusion of the need for long-term care.
2. In some states, qualified Medicaid enrollees may receive help from a waiver program they provide with the costs for personal care as well as some other support services beneficiaries receive in an assisted living setting.  This assistance can reduce the total cost of assisted living quite a bit.  However, Medicaid does not offer help with the costs of room and board in an assisted living facility.

Click here for more details on Assisted living coverage

Is there a way to get financial assistance for assisted living:

As stated above, several states provide help with assisted living costs for anyone who has limited financial resources and qualifies for help such as Medicaid.

Veterans may qualify for help through programs offered through their local VA.  These programs and VA benefits may offer help with the costs of assisted living.

Although Medicare does not cover assisted living facilities, it will cover cost for medical treatment provided by doctors or hospitals as well as some approved skilled nursing facility care. If prescription drugs are needed, they are covered by Medicare Part D.

Medicare agent application checklist

If you are a Medicare agent, you know there are some things you need to do to prepare before taking an application from a client.  Take a look at the suggestions in the Medicare application checklist below. are currently taking as well as their doctors. This is all important information that you need to run an accurate Medicare quote.

You can easily run a quote using one of our free online quoting and enrollment tools such as Sunfire or Connecture.  Both of these tools have a built in CRM that is free to use to our contracted agents.

Learn more about how to quote Medicare Advantage plans with our free quoting tools

Before you take the application

Be sure you get a signed SOA.  There are CMS guidelines agents must follow when taking a SOA.  Agents must take the SOA (Scope of Appointment) 48 hours before you meet your client to sign up for a Medicare plan.  Please note; a scope is good for 12 months from the date the client signs it.  After a 12-month period, you need a new scope signed before any Medicare enrollment discussions can take place.  You must keep a scope of appointment on file for 10 years weather or not you made a sale. per CMS guidelines.

Watch our YouTube video on Scope of Appointment rules starting 10/1/23

Click here to download a generic scope

It is important that the SOA is filled out correctly with the plan type that you are discussing during your meeting checked of or initialed.  There are a few ways to collect the SOA.  You can collect it on the phone, via voice recording, online by sending a link either by email or text and you can also collect a paper SOA.  This all depends on the client’s preference.

Using a paper application

It is important to write legibly in either black or blue ink.  This ensures what you submit is processed without delays.

1. If your client is enrolling in an MA/MAPD plan, be sure to include their PCP name and ID information requested on the enrollment form.  This is extremely important if they are applying for an HMO.  You should always check the client’s list of providers before enrolling them in any MA/MAPD plan.
2. In the event your client has to answer health questions, make sure they provide detailed explanations for any health questions they answer yes to.
3. If the client is enrolling during an SEP, be sure to include any necessary or required information.  If you try and skip this, it will only delay the processing and can result in a denial or enrollment.
4. Be sure the that not only the client signs wherever required but that you sign where needed as well. This goes for the scope of appointment too.
5. Submit the application on time.  Know the carrier rules for how long after you receive the application it must be submitted by.
6. Before submitting the application check everything over one last time so that there are not delays in processing and the client gets the coverage they need on time.  If you send you r application through Pinnacle, they will scrub it for you, but it is always better to double check before submitting it to them.

Submit the application electronically

One way to be sure the application is done correctly is to use one of our free online enrollment tools and submit the application electronically.  This will ensure that all information is provided, and that the application is filled in legibly.

Join the team at Crowe and Associates

Click here to view more images by this artist

Medicare Advantage open enrollment period

Everyone has probably heard about the Medicare annual enrollment period, but there is another opportunity to change your MA plan.  This is opportunity is available during the Medicare Advantage open enrollment period or the MAOEP.

The MAOEP basics:

1. This enrollment period starts on January 1 and ends on March 31 each year.  During this time MA/MAPD enrollees can make plan changes.
2. During this time MA/MAPD enrollees may switch to a different Medicare Advantage plan or back to Original Medicare.
3. If you make a change during this period, it will go into effect the first day of the following month after your application is submitted.

A few details about the Medicare Advantage open enrollment period:

Beneficiaries who switch from a Medicare Advantage plan to Original Medicare are eligible to purchase Prescription Drug Plan (Part D) coverage.

It is important to note; beneficiaries who have Original Medicare and Part D coverage cannot use this enrollment period to change their coverage.  This Enrollment period is exclusively for Medicare Advantage enrollees.

Another important thing to understand is; if you want to change from a Medicare Advantage plan to Original Medicare during this time, you may not have guaranteed issue rights for Medicare Supplement coverage. This depends on the state you reside in (there are only 4 guaranteed issue states) or how long you have had a Medicare Advantage plan.

Learn more about Medicare Supplement plan guaranteed-issue rights.

Most beneficiaries make plan changes during the AEP that runs from Oct 14 through Dec 7 each year.  It is the best time to change plans.  If you change during this time and you are not happy the MAOEP gives you a chance to change back or to another plan.  If you wait until the MAOEP, you cannot change plans again until the following AEP.

It is important to consider all your options carefully.  A licensed insurance agent can help you see all your options side by side and make an informed decision.

Keep in mind; making a plan change during AEP and having your new plan start in January is really the best way to keep your annual out-of-pocket cost down.  If you start the year with one plan and then change plans a few months later, you will have to start over with a new deductible and out-of-pocket maximum.

Watch some of our free training videos on YouTube

Click here to view more images by this artist

Does Medicare pay for assisted living

Many people have asked the question; does Medicare pay for assisted living.  The answer to this question differs depending on the type of Medicare coverage you have.

Original Medicare:

Medicare A & B (Original Medicare) does not cover the costs of assisted living.  Because assisted living is not considered medically necessary, it is not covered by either Part A or Part B.  Although, Medicare will provide coverage for approved short-term stays in skilled nursing facilities after inpatient hospital stays. Once the patient has reached 20 days in skilled nursing, there is a $200 a day coinsurance charge.  After 100 days, the beneficiary is responsible for 100% of the cost.

Original Medicare does cover some home health care services as well as hospice care.  Although Original Medicare does not cover assisted living, it does cover all approved medically necessary services under Parts A and B.  This includes hospital stays, medical procedures, screenings and visits to the doctor.

Medicare supplement plans:

Medicare supplement plans are used with Original Medicare. In general, they help cover the deductibles, co-pays and co-insurance that remain after Original Medicare pays its portion. It is in place to supplement Original Medicare.  Therefore, it does not cover assisted living or long-term-care.

Medicare Advantage Plans:

Medicare Advantage plans provide the same coverage as Original Medicare, Parts A and B.  MAPD plans are offered through private health insurance companies.  Most of these plans include prescription drug coverage as well as additional benefits.

Medicare Advantage plans do not cover assisted living costs. However, there are some plans that cover specific services that are similar to assisted living facilities.  These services may include providing coverage for assistance with the activities of daily living, such as transportation to doctors’ appointments and even meal delivery.

Assisted living coverage for dementia patients:

People who have dementia, are eligible for help from Medicare to pay for hospital stays, home health care, skilled nursing home care, hospice care, cognitive assessments and necessary medications. Some eligible patients with Alzheimer’s and dementia may receive payment assistance for care planning. Original Medicare does not provide payment for dementia care however, both Medigap and Medicaid may provide help paying for it.

Ways to pay for assisted living:

The cost of assisted living varies greatly depending on where you live and what the facility provides as well as what each individual requires in terms of care.

1.  One of the best ways to pay for assisted living is through a long-term care policy.  Unfortunately, by the time most people think about it, they are older may not be easily affordable for most individuals. If you are fortunate enough to purchase it while you are young enough that the prices are reasonable, there are many options to choose from.  Look carefully at all the rules and conditions before choosing a policy.
2.  Some people have the foresight to put a large sum aside for such instances.  You may have access to funds from savings, pensions of other sources.
3. Many states provide Medicaid waiver programs that can help pay for medication management, on site therapy or support services in a residential setting.  Medicaid does not pay for the cost of room and board.
4. Eligible veterans may receive assisted living benefits through their local VA.  This benefit may also be available to veterans through some approved non-VA facilities.
5. One more option is through funds obtained through a reverse mortgage.  Unfortunately, if you stay in an assisted living facility for over a year and your home is vacant, the reverse mortgage has to be paid back, this is often done by selling your home.  It is best to speak with a qualified financial counselor before taking this step.

Medicare commissions 2024

If you are a Medicare agent or thinking about going into the Medicare business, you should be aware of the Medicare commissions 2024.  We are happy to announce that CMS has released the maximum broker commission amounts for 2024.

It is important to note; insurance providers do not have to offer the maximum commission amounts.  It is just a guideline decided by CMS each year, what each insurance provider pays out is up to them.

The good news is; the amounts have gone up for the 9th consecutive year!

Maximum commissions for Medicare advantage plans 2024:

It is important to note: all commission rates are not the same.  They vary by state they are available in.

In the sates of both CA and NJ, the initial commission rates have increased from $750 per member for the year to $762 per member for the year.  This is an increase of 1.6% YOY.  The renewal commissions for CA and NJ have gone up from $375 per member for the year to $381 per member for the year.  This also adds up to an increase of 1.6%.

The states of CT, DC and PA have had an increase in initial MA commissions from $678 per member for the first year to $689 per member for the first year. This adds up to an increase of 1.62% YOY.  Renewal commissions for CT, DC and PA have increased 1.77%. Renewal commissions will go up from $339 per member per year to $345 per member per year.

Both Puerto Rico and the U.S. Virgin Islands initial MA commissions have gone up from $411 per member for the year to $418 per member for the year, this amounts to an increase of 1.7% YOY.  The renewal commissions have increased from $206 a member for the year to $209 per member for the year, this is equivalent to an increase of 1.46%.

In all other states not listed above, the initial MA commission amounts have increased 1.66% YOY from $601 per member for the year up to $611 per member for the year. Renewal commissions have also increased at a rate of 1.66% from $301 per member for the year to $306 per member for the year.

If you are interested in becoming a Medicare agent; click her to learn more

Maximum commissions for PDP plans 2024:

The commission rates for PDP plans are the same in all states.

Initial commission rates for PDP plans have gone up by 8.7% YOY.  This means commissions have gone from $92 per member for the year to $100 per member for the year.  Commissions for PDP plan renewals have also been increased by 8.7% YOY. Commissions have ow gone from $46 per member each year to $50 per member each year.

Click here to see CMS carrier commission chart for 2024

Take a look below to see the 2023 & 2024 commission rates side by side.

Learn why Crowe and Associates is a great choice for your FMO

Subscribe to our YouTube channel and watch our informative videos

Click here to view more images by this artist

Medicare sales permission to contact

When you have a potential clients you need to keep all the CMS guidelines in mind before you begin.  You need to be compliant and use a Medicare sales permission to contact.

What is Permission to Contact:

This process helps stop agents from contacting beneficiaries through the use of dishonest sales tactics. Unfortunately, in the past, some agents have pressured Medicare beneficiaries to get a Medicare sale.  Permission to contact is one way to help deter uninvited agents to approach beneficiaries when they are not prepared.

To avoid non compliance, it is important the beneficiary gives permission for the agent to contact them before you try and meet, call or email them for Medicare Advantage or PDP sales.

Here are some ways you can contact a potential client:

1. You can return their call if they request you do so.
2. Through email as long as there is an opt-out option clearly provided.
3. If they respond to a business replay card.
4. When they fill out an online contact form.

Here are some ways you cannot contact a potential client:

1. Do not knock on a potential client’s door without an invitation.
2. You are not permitted to send texts to anyone without their permission.
3. Directly contact through social media

When is permission to contact required:

Anytime you want to contact a potential client, you should obtain permission to contact.  This is very important if they may be considering a Medicare Advantage or Prescription Drug Plan enrollment. Please note; even if you contact a potential client for a Medicare Supplement plan which does not require permission to contact, they will most likely need a Prescription Drug Plan to go with it, therefore it is always a good idea to have permission to contact.  Be sure to include the following disclaimer “This is a solicitation of insurance” on the Permission to contact form.

Please note: If you are contacting your own clients; you do not need permission to contact.

It is acceptable to email potential clients as long as you include an opt-out option.  You cannot send anything that could be considered marketing material.  Marketing material includes specific plan information such as premiums, co-pay amounts or other benefit information. All communications must meet CMS guidelines as well as  CAN SPAM Act requirements.

How long is the permission to contact good for:

Once you have collected the permission to contact, you have 12 months to contact that beneficiary.  If you do not contact them within that time, you must collect another PTC before contacting them.

A couple more things to note:

If you employ a third party marketing organization for lead generation, it is important that they are compliant with all the CMS rules.  Do not forget, it is your name on the materials they are sending so you are the one who is ultimately responsible for what goes out to the public.  Beneficiaries need to be told either verbally, in writing or electronically depending how they are contacted, that their information will be given to a licensed Medicare agent who will contact them.

Do not confuse permission to contact with a Scope of appointment.

You still need to collect a scope of appointment from the beneficiary once you are able to set up a meeting or call to go over plan options.  It is important to follow all guidelines for Medicare sales in order to maintain compliance and maintain your ability to offer Medicare plans.

Download a generic scope of appointment form

Get contracted with the Crowe team!

To view more images by this artist; click here

Medicare HMO vs. PPO plans

If you are considering a Medicare advantage plan, you will need to weigh Medicare HMO vs. PPO plans.  The first thing we need to do is explain that HMO stands for Health Maintenance Organization plans.   On the other hand, PPO stands for Preferred Provider Organization plans. Each of these plans provide its own set of benefits.  The plan you choose will impact your healthcare experience.

Understanding the Basics:

Medicare HMO and PPO plans operate within the broader framework of Medicare.  Both types of plans cater to the healthcare needs of Medicare beneficiaries.  Although the share the goal of providing essential healthcare coverage, they function differently in terms of network flexibility, cost structure, and coverage options.

Medicare HMO Plans:

HMO plans typically require beneficiaries to choose a primary care physician (PCP).  The PCP coordinates their care as well as provides referrals to specialists within the HMO network. This approach supports a structured healthcare management system.  This ensures a comprehensive and coordinated approach to treatment.

Additionally, Medicare HMO plans often come with low premiums and lower out-of-pocket costs when compared to some PPO plans. They also may provide some benefits such as a Part B giveback that PPO plans typically do not. However, the trade-off for these cost savings is the restricted network access.  This may limit the choice of healthcare providers and facilities.  In most cases HMOs do not cover medical care received outside the HMO network, except in emergencies or urgent care situations.

Medicare PPO Plans:

On the other hand, PPO plans offer more flexibility in choosing healthcare providers and facilities.  This allows beneficiaries to seek treatment both in and out of the PPO network. Although there is a network of preferred providers, beneficiaries can still access care from out-of-network providers.  It is important to note; out of network services will have a higher cost to beneficiaries than in-network.

In general PPO plans may have a higher premium and greater out-of-pocket costs when compared to HMO plans. Nonetheless, the flexibility to see specialists or visit healthcare facilities without referrals can be advantageous.  This is helpful for those who require specialized care or have established relationships with trusted providers.

Key Considerations for choosing a plan:

When deciding whether an HMO or PPO plan best suits your needs, there are several key factors to consider:

1. What are your healthcare needs – Think about your healthcare requirements, this includes how often you require the care of a specialist.  You may need to go out-ot-network for some providers.
2. Cost Considerations – Compare the premiums, deductibles, and co-pays associated with both plans. Do not discount potential out-of-network costs for either plan.
3. Provider Network – Research the size and quality of the provider network. It is important to consider the availability of preferred doctors and specialists within each plan.
4. Network area – If you frequently travel or reside in multiple locations throughout the year, it is important to consider the geographic area of coverage available.
5. Prescription Drug Coverage – It is very important to research the prescription drug coverage provided by each plan.  This is imperative if you require regular medications.

Making the Right Choice:

Ultimately, the decision between a Medicare HMO and PPO plan hinges on your individual healthcare needs, financial circumstances, and preferences.

While HMO plans offer cost-effective, structured care within a limited network, PPO plans provide greater flexibility at a higher cost. Carefully evaluate your healthcare priorities and compare the specifics of each plan to make a well-informed decision.

It is a good idea to consult with a trusted healthcare advisor.  A licensed Medicare agent can help you review plan documents thoroughly and find the best option for you. A well informed agent can also answer your health coverage questions and is available to you when you need them.

Licensed agents get contracted with Crowe

To view more images by this artist; click here

Medicare AEP Marketing

It’s no secret that the Annual Enrollment Period (AEP) can be the most stressful time of the year for insurance agents. It’s imperative that you try to communicate with and service nearly your entire book of business in a less than eight-week-long time period. Other than the mandatory steps like making sure all your business practices are in compliance with the new CMS regulations and guidelines, what can you do now to prepare for a less stressful AEP? We have five Medicare AEP Marketing tips sure to improve your work-life balance during the next few months

Get personal

How large is your book of business? Is it 250 clients or less? If so, you might be an ideal candidate for a more intimate approach – your clients will like that you’re speaking to them like individuals in your marketing material and fewer than several hundred clients is still pretty manageable. Some agents use postcards, some use emails, some mail greeting cards! There are many ways to reach out, but the goal is the same: make your clients feel like you’re invested in their best healthcare outcome before the start of AEP.

Start communicating in September

In the second half of September, it can be helpful to ask your clients to create Medicare.gov accounts if they do not already have them. This makes collecting and comparing data all the more essay, including more accurate drug comparisons. Getting this done in September will make October and November, Medicare AEP Marketing run more smoothly.

Hire seasonal help or interns

If it’s a reasonable expense for your business, consider hiring some seasonal help. How much easier would your AEP be if there was somewhere there to answer the phone, or return emails, or keep track of which clients need a call back? Anything they can take off your plate during the busiest eight weeks of the year would probably make a world of difference.

Try an online scheduling system

There are lots of options out there, but two that are easily integrated into websites are Calendly and TimeTap. Depending on how busy you are and how technologically savvy your clients are, it might make sense to have a way for them to book an appointment with you on their own via the website.  Automate appointments as part of your Medicare AEP Marketing.

Find an outlet!

No matter how well you manage your time and resources, AEP is going to be busy. Finding an outlet to better manage your stress can make a world of difference, no matter what it is.

With these five tips, you can set yourself up for a better work-life balance during this Annual Enrollment Period.

Licensed Medicare Agents

Medicare AEP Marketing – Click here to see what Crowe and Associates has to offer 

Keep up with all of our current events by clicking here. 

Ready to contract?   Begin here.

Subscribe to our YouTube channel.   We provide weekly training.

Click here to view more images by this artist