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Agents and beneficiaries need to understand the actual cost of any healthcare plan they are considering. That being said; we will explain deductibles vs out of pocket maximums and how they apply to your clients’ coverage.

Many health insurance plans have both a deductible as well as an out of pocket maximum. Both terms refer to a specific amount the beneficariy must pay each year before their insurance provides a specific level of coverage. Once the enrollee meets the dedcutible, the insurance plan pays the specified portion of eligible cost. On the other hand, once the enrollee meets the the out of pocket maximum, the insurance plan pays the entire cost for all covered services.

Deductibles

The amount an enrollee pays out of pocket for eligible services before the insurance plan covers their portion of the costs is a deductible. The amount of the deductible varies by plan and is specified in the summary of benefits or evidence of coverage for each plan.

Keep in mind, each type of coverage has it’s own deductible, for example; Medicare Part B, has one specific annual deductible for all enrollees. Medicare Part A has a hosptial deductible that the enrollee must meet each time they are admitted into the hospital (except in specific situations). Many Part D (prescrption drug plans) have an annual deductible that varies depending on the plan.

Find out about Medicare costs for 2024

Out of pocket maximums

An out-of-pocket maximum is the most a beneficiary pays out of pocket annually for covered healthcare expenses. Once the beneficiary reaches this limit, their insurance plan covers 100% of the costs of covered benefits. Deductibles, copays, and coinsurance are all included in this amount. It does not include expems premiums, balance-billed charges, or services that Medicare does not cover.

Learn more about out of pocket maximums

Additionally, several types of payments count towards the out of pocket maximum including; deductibles, copays and coinsurance. The plan’s monthly premium does not count toward the out of pocket maximum.

Please note; Original Medicare and supplements do not have an out of pocket maximum.

Additional information

Each year the deductible amount is subject to change. The deductible does not apply to many preventative services, such as annual check-ups, immunizations and vaccines. Most insurance plans cover these serices at 100%.

For those enrolled in a healthplan with a deductible and an out of pocket maximum, the amount paid toward the deductible applies to the maximum out of pocket cost. They continue to pay copays and coinsurance costs until they reach the out of pocket maximum.

Consider all costs before choosing a plan

There are many plans available with different deductibles and out of pocket maximums. That is why it is important for individuals to be aware of all costs associated with the plan they choose. A licensed insrance agent can help provide a comparison of plans that offer the coverage and costs each beneficiary is looking for. Each year during AEP, Medicare beneficiaries have an opportunity to meet with their agent to review their plan cost and coverage and make any changes necessary.

For the most part, Medicare clients are happy with their coverage and the services they recieve, although there are times they may have questions or complaints about Medicare service.

The problem could be due to issues with their plan, providers or customer service experiences. If problems occur, enrollees have the right to file a grievance. Unlike appeals, which address denials of coverage, a grievance is a formal complaint about other aspects of Medicare services or care. We explain what constitutes a complaint/grievance, the steps to file, and how to ensure your clients receive a resolution.

Medicare grievances/complaints

A Medicare grievance is a complaint about issues related to Medicare plans or care that are not about payment or coverage decisions. Here are a few common reasons for complaints:

1. The quality of care or service they recieved.
2. Patients may feel a facility is not clean or safe enough.
3. There may be issues with the behavior of a helathcare provider or plan representative.
4. Patients may experience unreasonable delays in getting an appointment or service they need.
5. The plan may have given enrollees incorrect or misleading information.

How to file a complaint

Identify the issue and gather information

Clearly identify the issue that prompted the complaint. Make sure you have all relevant details, including dates, names of individuals involved, and supporting documents such as; medical records, bills, or correspondence.

Contact the plan or healthcare provider

In order to resolve a grievance, the beneficiary must contact their Medicare plan or healthcare provider directly. In many cases, the issue is resolved through direct communication. This will eliminate the need to file a formal grievance.

Prepare the complaint/grievance

If the beneficiary is not satisfied with the resolution, they should file a formal complaint/grievance.

Write a Detailed Account: Clearly describe the problem, include who was involved, what happened, when and where it occurred, and why you are dissatisfied.

Include Supporting Documents: Attach copies of any relevant documents (medical records, bills or correspondence) that support your issue.

Submit the complaint

The submission process varies depending on the type of Medicare coverage.

Original Medicare: Enrollees file their complaints with the healthcare provider or facility where they received care.

Medicare Advantage (Part C) and Prescription Drug Plans (Part D): Enrollees file their complaint/grievance with their plan provider. They will find plan contact information and instuctions for filing in the plan’s member handbook or on their website.

Learn what Medicare advantage plans don’t cover; click here

Adhere to filing deadlines

Medicare requires beneficiaries to file complaints within 60 days of the event that caused the issue. The plan or provider must respond to the complaint within a specific timeframe. Urgent issues require an response within 24 hours while non-urgent issues have a 30 day repsonse timeframe.

Follow up

Plan enrollees should keep records of their complaint/grievance submission and follow up if they do not receive a reply in a reasonable amount of time. Persistance ensures that concerns are addressed in a timely and satisfactory manor.

Tips for Filing a Successful Grievance

Be clear and concise: Clearly state the issue and the desired outcome.

Document Everything: Keep thorough records of all interactions. Include dates, times, names, and what was discussed.

Be Polite but Firm: Maintain a professional tone, but be firm in expressing dissatisfaction and the desired outcome.

Seek Assistance: For those who need help filing a complaint/grievance, contact a State Health Insurance Assistance Program (SHIP). They provide free, unbiased counseling and assistance. The official Medicare website, medicare.gov, provides comprehensive information on filing grievances and appeals. Beneficiaries can also call 1-800-MEDICARE for help with Medicare related issues.

Although filing an official complaint/grievance with Medicare seems daunting, knowing your rights and understanding the process can help effectively address issues and improve the healthcare experience. Remember, client feedback is one important way to improve on the services provided to Medicare beneficiaries.

Agents provide support and assistance to clients

Although these issues may not involve agents directly, you are your clients’ point of contact for their health coverage needs. It is important to be available to them for guidance if they have healthcare or coverage issues. That is why a basic understanding of how to handle complaints/grievances is good to have.

Click here for some tips on maintianing your book of business

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Understanding the Medicare out-of-pocket maximums is important for agents as well as clients. The amount changes each year; it is imperative to stay up to date on this information. This number may be a big factor for those who want to manage their healthcare expenses.

Out of pocket maximums

An out-of-pocket maximum is the most a beneficiary pays each year for covered healthcare expenses. Once they reach this limit, their insurance plan covers 100% of the costs of covered benefits. Deductibles, copays, and coinsurance are all included in this amount. It does not include premiums, balance-billed charges, or services that Medicare does not cover.

Medicare and out of pocket costs

Medicare is divided into different parts, each has its own rules for out-of-pocket costs.

Original Medicare (Part A and Part B)

Original Medicare does not have an out-of-pocket maximum. In other words, there is no cap on the amount beneficiaries can pay each year for healthcare services. This concern beneficiaries who require extensive medical care, as there is no financial limit to their liability.

Part A (Hospital Insurance): Part A covers inpatient hospital stays, skilled nursing facility care, hospice care, and some home health care. Although is no out-of-pocket maximum, enrollees are responsible for deductibles and coinsurance payments.

Part B (Medical Insurance): Part B covers outpatient care, preventive services and medical supplies. Part B is similar to Part A, there is no out-of-pocket maximum; beneficiaries pay the deductible and coinsurance.

Medicare Supplements

Medicare supplements also do not have an out of pocket maximum. This is due to the fact that it is not necessary because of the benefits these plansprovide. They cover most of the costs left behind by original Medicare; therefore, a maximum out of pocket amount is unnecessary.

Medicare Advantage (Part C)

Medicare Advantage plans, (Part C), are offered by private insurance companies approved by Medicare are an alternative to Original Medicare. One of the benefits of Medicare Advantage plans is they include an annual out-of-pocket maximum.

Although CMS sets a maximum each year that these plans cannot exceed, each plan sets its own annual limit. In 2024, the maximum out-of-pocket limit is $8,850 for in-network services and $13,300 for combined in-network and out-of-network services. Once enrollees reach this limit, the plan covers 100% of eligible healthcare costs for the rest of the year.

Medicare Prescription Drug Plans (Part D)

Medicare Part D provides prescription drug coverage and is available as a stand-alone plan or included in some Medicare Advantage plans. Most enrollees of part D plans have a deductible, co-pays and coinsurance. These costs apply to prescription medications on certain tiers of the plan formulary. Part D plans also have a coverage gap that can affect out-of-pocket costs.

Coverage Gap and Catastrophic Coverage: In 2024, once the benficiary and their plan have spent $4,660 on covered drugs, they enter the coverage gap. During this period, they pay no more than 25% of the cost for prescription drugs. Once out-of-pocket costs reach $8,000, they enter catastrophic coverage, and pay nothing for covered medications for the rest of the year.

Watch a video about the changes in drug coverage for 2025

Manage Out-of-Pocket Costs

Because of the potential for high out of pocket costs, it is a good idea to try and mange them ahead of time.

Choose a Medicare Advantage Plan: Consider a Medicare Advantage plan with a low out-of-pocket maximum to help control medical costs. These plans can provide financial protection and predictability.

Supplemental Coverage: Purchase a Medicare Supplement plan if you have Original Medicare. These plans help cover some out-of-pocket costs left over after Original Medicare pays its share.

Review plan coverage: Each year, enrollees should review the annual notice of change from their Medicare plan to understand changes in coverage, costs, or out-of-pocket maximums. It is also important to meet with a licensed Medicare agent and go over all your options to ensure you have a plan that best meets your healthcare and financial needs.

Prescription Drug Assistance Programs: Look into programs that offer assistance with prescription drug costs, especially if you are in the Part D coverage gap.

Learn about changes to the coverage gap (donut hole) for 2025

Preventive Care: It is best to use preventive services from an in-network provider. Staying on top of your health helps to avoid serious problems down the road.

Understanding and managing out-of-pocket maximums is essential for anyone on Medicare. While Original Medicare lacks an out-of-pocket maximum, Medicare Advantage plans provide a valuable safety net. By exploring supplemental coverage options and being proactive about healthcare decisions, beneficiaries can better manage their medical expenses and ensure they receive the necessary care without financial strain.

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Sometimes Medicare coverage is great and other times it is a challange. This is especially true when it comes to denials of coverage. If your client receives a denial, it’s essential to let them know they have the right to appeal. Understanding the Medicare appeals process can help your clients get the coverage they need. In this post, we provide a guide to help with this process.

Understand your coverage

One very important thing agents can do to help avoid denials of coverage; ensure clients understand their coverage. Discuss what each plan covers and what the beneficiary is responsible for such as copays, deductibles and coinsurance amounts. Licensed Medicare agents can help beneficiaries go over plan choices and ensure the beneficiary has the best coverage for their personal situation.

Agents can also discuss gaps in coverage and offer additional ways clients can cover themselves if anunexpected health problem comes up.

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Medicare Appeals

Medicare appeals are requests to review and reconsider decisions about healthcare coverage and payments. These appeals may be necessary when Medicare denies a beneficiarie’s request for a healthcare service, supply, or prescription drug, or refuses to pay for services they have received.

Click here to access appeals forms on CMS.gov

How to appeal a Medicare decision

Review the Notice of Denial

It is important to carefully read and understand the notice of denial before initiating an appeal. This document, often called either a EOB (explanation fo benefits) for Medicare advantage (Part C) or Part D plans or a MSN (Medicare summary notice) for Original Medicare, explains why coverage of the service or item was denied.

The plan must explain how to appeal the denial in writing. After the beneficiary files the appeal, the plan reviews its decision. If they do not agree with the appeal, an independent Medicare organization reviews the decision.

Understand Appeal Rights and Deadlines

There are very specific deadlines in place to file an appeal. The deadline varies by the type of Medicare coverage an beneficiary has.

Original Medicare (Part A and Part B)

The beneficiary has 120 days from the date they receive the MSN to file an appeal.

Medicare Advantage (Part C) and Prescription Drug Plans (Part D)

When a beneficiary of one of these plans wants to file an appeal, they have 60 days from the date they receive the EOB to file the appeal.

Collect Supporting documentation

Beneficiaries should gather any medical records, doctor’s notes, and any other evidence that supports their case. A healthcare provider is an invaluable resource to help provide documentation and expert opinions to help make the appeal successful.

If the beneficiary’s doctor agrees that they have are at serious risk, worsened by waiting, the plan must make a decision within 72 hours of receiving the request.

Click here to learn more about getting a fast appeal

Submit the appeal

The appeals process for Original Medicare and Medicare Advantage/Part D plans differs slightly.

For Original Medicare (Part A and Part B)

Fill out the redetermination request form included with the MSN or write a letter to the address listed on the MSN. It is important to include the beneficiaries’ name, Medicare number, the specific item or service in the appeal as well as any supporting documents. A Medicare contractor reviews the appeal.

For Medicare Advantage (Part C) and Part D (Prescription Drug Plans)

Appeals are submitted directly to the plan for reconsideration. The EOB has instructions on how to submit the appeals. If the initial appeal is denied, enrollees can request an independent review by a third-party organization.

Levels of Appeal

If the initial appeal is denied, there are many ways to escalate it.

1. Request reconsideration by an independent review entity.
2. If the amount in question reaches a specific threshold, you can request a hearing by an administrative law judge.
3. If the beneficiary is dissatisfied with the administrative law judge’s decision, enrollees can request a Medicare appeals council review.
4. If all else fails, the enrollee can file a lawsuit in federal district court.

Follow Up

Make sure beneficiaries keep copies correspondence or records related to the appeal. Always follow up on the status of the appeal and be sure to adhere to all deadlines.

Ensure a successful appeal

Be persistent; because appeals can take some time, it is important to be persistent. Don’t let initial denials discourage you.

Ask for assistance; use State Health Insurance Assistance Programs (SHIPs), which provide beneficiaries free assistance with Medicare appeals.

Organize all helpful information: it is essential to maintain a well-organized file of documents, correspondence, and any notes related to the appeal.

For help filing an appeal, contact the SHIP State Health Insurance Assistance Program.

Although Medicare denials and the appeals process may be discouraging, understanding the beneficiaries’ rights and the necessary steps makes the process manageable. Being thorough, organized, and persistent, improves the chance of a successful outcome for the appeal.

Understand your coverage

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For an agent to explain Medicare coverage to a client, they need to understand the difference between coinsurance vs copays. These as well as other out-of-pocket costs affect the total cost of a Medicare beneficiaries’ annual healthcare.

Coinsurance

After an enrollee meets their annual deductible, the percentage of covered medical expenses they pay is coinsurance. If a beneficiary enrolls in Original Medicare, Medicare pays 80% of the cost for approved expenses (after the deductible is paid) the beneficiary pays the remaining 20% until they reach the annual out-of-pocket maximum.

Please note, if the beneficiary has expenses that are not Medicare approved, coinsurance does not apply to these expenses. In that case, the beneficiary must pay for the entire cost of the medical service.

Coinsurance and the deductible

Coinsurance is the percentage of healthcare costs the beneficiary pays after the cost for medical care goes beyond the deductible amount.

Copays

Are predetermined amounts plan enrollees pay medical providers when they receive approved medical services. Copay amounts can be as low as $10 and go up quite a bit from there. The amount varies by plan and is usually higher for specialist services. There are different copay amounts for each type of service such as primary care provider visits, specialists, urgent care, visits to the ER as well as for prescription medications.

Copays and deductibles

Even if you have not met your annual deductible, you will have to pay the copay amount in addition to the deductible. In most cases, copay amounts do not count toward the annual deductible. However, copays do count towards the out-of-pocket maximum for the year.

Watch a YouTube video of what you need to know before a Medicare sale

Coinsurance vs Copays summary

Coinsurance:

1. The amount is a percentage of the cost for a procedure.
2. All approved medical procedures charge the same percentage amount.
3. Coinsurance goes into effect once the enrollee meets the annual deductible.

Copays:

1. The copay is a predetermined amount enrollees pay for each visit.
2. Amounts change depending on the type of provider the enrollee uses for a procedure.
3. Enrollees pay the copay amount weather or not they meet the deductible.

Deductibles

In order to better understand how coinsurance and copays differ, we will explain deductibles. Deductibles are a set amount of money beneficiaries pay annually for their healthcare before their health care plan kicks in and pays its share of covered medical costs.

Summary

1. A copay is a set amount enrollees pay for primary care, specialists, ER and urgent care as well as prescriptions.
2. Coinsurance is a specific percentage of approved medical costs enrollees pay once they meet their annual deductible.
3. Deductibles are predetermined amounts enrollees pay for various types of medical care before coinsurance goes into effect.
4. If an enrollee meets the annual out of pocket maximum, their plan covers all approved medical expenses at 100%.

Learn more about Medicare costs, click here

Coinsurance vs copays

Additionally, copays and coinsurance does not usually apply to preventative services. In other words, most health plans cover these services at 100%. In most cases, plans with higher copay amounts have a lower premium.

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In the world of insurance sales, objections are inevitable. When it comes to selling Medicare, agents often encounter various objections from prospects. Often times, there are concerns about cost, coverage, or confusion about the options available. Addressing objections effectively is key to closing the sale. In this post, we explore practical strategies to overcome objections in Medicare sales.

As with all Medicare sales, be sure you follow all CMS guidelines and follow compliant sales practices .

Learn the key elements for a compliant phone recording

Listen

The most crucial skill in overcoming objections is active listening. When a client raises an objection, listen attentively to fully understand their concerns. Don’t interrupt or immediately start a counterargument. Instead, show genuine interest and empathy. This will establish rapport and provide valuable insights into the client’s needs and preferences.

Empathize

Acknowledge the client’s concerns and validate their feelings. Empathizing with their situation helps build trust and rapport. Express empathy by letting them know you understand their concerns and that their questions are valid. This shows you understand them and will try to make them feel confortable expressing them to you.

Educate

In many instances, objections come up due to a lack of information or a misunderstanding. Take the time to educate clients about Medicare coverage options, benefits and available plans. Provide clear explanations tailored to their specific needs and preferences. In some cases, you may need to send a brochure or use online resources like websites or zoom meetings to provide a visual aid to help expalin complex information.

Address concerns

Always remember, each client’s objections are unique. Tailor your responses, so tailor accordingly. If a client is concerned about out-of-pocket costs, discuss Medicare plans that offer cost-saving benefits, such as low premiums, low copays or value added benefits.

Offer solutions

Do not dismiss objections; provide solutions that address the client’s concerns. For example, if budget is the main objection, discuss Medicare plan options with varying premiums or if appropriate, discuss financial assistance programs. Providing personalized solutions shows the cleint you are able to meet their client’s coverage and budgetary needs.

Common objections and how to respond

Why are you calling

Let the prospect know where you got their information from and let them know you are a licensed agent who provides free consultations for Medicare enrollees. Tell them you called to answer any questions they have and from there see what products they are interested in discussing.

Not interested

Acknowledge the objection and request a few minutes to explain the potential to save a significant amount of money on healthcare costs and add needed coverage. Give them an idea of how your advice can benefit them.

Already have a plan/agent

Ask if anyone explained the differences of Medicare Advantage and Medicare Supplement plans. If they are not sure, go ahead and let them know you can check and make sure they have the best coverage for their needs.

Here are a few ways to maintain your Medicare book

Ask when they last spoke with their agent and offer to go over any changes in available benefits. Ask them a few questions to determine if they have any coverage gaps. Find out if their agent mentioned ancillary products like cancer or hosptial indemnity insurance and discuss the value this coverage provides.

Watch a quickYouTube video on the benefits of ancillary sales

Not on Medicare yet

Find out if they plan to retire in the near future and see if they would like to schedule a call to put a plan in place. Make sure they understand the penalties for late enrollment and offer to assist in a smooth transition process.

Don’t want to change plans

Understand what they are saying, validate their response and ask if you can contact them at another date and time when you have updated plan information they may want to consider. Ask if you can mail them your contact information in case they have quesitons and want assistance.

Need to ask a friend/family member

Let them know you are happy to speak with that person as well to go over the information so they are all comfortable with any changes.

Don’t want to give information over the phone

Be understanding, you are a stranger to them asking for personal information. Many people are leery of phone scams and need to be reassured of the reasons why you need the information. If they are just not comfortable answering questions on the phone, if possible, schedule an in person meeting to go over their information and present coverage options.

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Make the sale

After all objections are addressed, you have the opprotunity to present them with coverage options that fit their medical and budgetary needs. Be sure to emphasize the benefits of enrolling in a plan tailored to their needs and reassure them you will provide ongoing support and guidance.

Get some tips for telesales

It is not always easy to overcome objections in Medicare sales. Successful agents provide a combination of active listening, empathy, education, and solution-focused communication. By understanding clients’ concerns, providing relevant information, and offering personalized solutions, agents can navigate objections with confidence and successfully make the sale.

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In most cases, Medicare agents try to do their best to ensure their clients are in a plan that fits their medical as well as financial needs. However, there are times when a client may be unhappy with the service they receive for one reason or another. When this occurs, they may decide to file a grievance with either a carrier or the state. If this happens, agents need to know ho wto handle complaints properly to avoid making things worse.

Medicare agents understand that handling carrier complaints is part of our profession, as CMS continuously updates the rules to conduct business. Addressing the issue quickly and correctly is essential. Here are some suggestions for handling complaints and ensure compliance and avoid escalation.

Try to prevent complaints

The best way to handle a complaint is to try and avoid them as much as possible.

follow all CMS guidelines.

Make sure you know all the rules before you host an event whether it is educational or a sales event, there are definite rules to follow. Be sure you have all the updated regulations before you do anything that could lead to a complaint.

Watch our YouTube video for what you need to know before a Medicare sale

Collect Scopes

This is a big one! It is imperative that you collect a SOA and be sure you do it in the correct way. The Scope is an important tool that not only protects the Medicare beneficairy but the agent as well. Scopes prove that you had permission to talk to the beneficiary and what you had permission to discuss. There are a few different ways to collect a scope; in writing, electronically (by email) or with a voice recording.

Learn how Retireflo can help you maintain compliance

Check client information

Before you enroll a client in any plan, you must ensure they have the best choices available to them. Agents must check all their current providers to ensure they are in network with the plan the client chooses. It is also very important to check all medications and explain how the plans cover each medication.

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How to handle complaints

Watch for carrier communications

Check your emails regulary and be sure to pay attention to any carrier communcations you receive.
If there has been a complaint field agianst you, the carriers normally communicate it to you via email. This helps avoid delays in your response and gets allegations cleared up in a timely manor. Because complaints have a deadline for a response, not repsponding in a timely manor, could make things much more difficult.

Think before responding

If you receive a complaint or allegation, it is important to take time and read it carefully. Be sure to follow carrier instructions before you respond. In most cases, you will be asked to answer some questions in response to the allegation. Answer each question as accurately as you can.

Provide documentation

Make sure to provide any supporting documents you have. Documents may include; scopes, enrollment recordings or even a copy of the signed application. Be prepared to provide any evidence the carreir may request that can help support your actions.

Contact your upline

If you currently have an upline, it is a good idea to have them review your answers before the response deadline and provide any constructive feedback. They should suggest any needed revisions to help ensure the situation is resolved. Be sure to edit your answers if necessary.

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If you are a Medicare agent with a large book of business you may wonder where to focus; existing clients vs new business. We will go over the benefits of focusing on each one and why you should put effort into both. Each one adds to the bottom line of your business and help it keep going.

Existing clients (Medicare Book of Business)

In general, Medicare clients want to build a long term relationships with their Medicare agent. Clients want to feel confident in the person who provides guidance on their healthcare coverage. They need to know they have someone to turn to for questions and concerns who has their best interest at heart.

It is important to contact them throughout the year to ensure they are happy with their coverage. It is especially important during the AEP to compare current coverage to new options. Existing clients bring in a steady stream of income as well as the potential for new business. These clients often help bring in new clients when they recommend their agent to family and friends.

Learn more about maintaining your Medicare book of business

New business

The importance of expanding your Medicare book is obvious. If you want to keep your business growing and generate more income, you need to add new clients. There are many ways to find new clients including through recommendations of existing clients. Our agents have access to some great lead companies as well as a seminar sales program that has been proven to be very successful. Another good way to meet new prospects is by setting up a table at local events and providing free Medicare guidance to those who ask for it. This to get their name out there as trusted a source for information.

Learn how to get more Medicare referrals

Effective marketing strategies as well as community outreach help establish you as a trusted resource. I tis alwyas importnat to follow all permission to contact rules as well as any CMS marketing guidelines before hosting any event or initiating contact with potential clients.

If you are an agent looking for the right FMO, click here to see what we have to offer.

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Existing clients vs. new business

Please note; successful agents put in the effort required to maintain their books as well as to add new clients to it. Once your book reaches a certain level, it may be wise to hire office staff and adjust your stategy to ensure both old and new clients receive the service they deserve. Setting both long and short-term goals for your agency will help keep you on track.

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Because there are a few different options when it comes to Medicare coverage, the question; does Medicare cover ER visits, has more than one answer. Each type of Medicare plan provides coverage for emergencies in a specific way.

In general, Medicare covers ER services when a beneficiary suffers from an injury or sudden illness that quickly worsens.

Original Medicare

If an individual enrolled in Original Medicare goes to the ER, they receive coverage for services from Medicare Part B. As long as they receive service from a either a hosptial or medical faciltiy that accepts Medicare. Additionally, Medicare Part B covers urgent care treatment for sudden illnesses or injuries that do not quailfy as a medical emergency.

Please note; emergency or urgent care a beneficiary receives is subject to a 20% copay as well as the annual Part B deductible. If an individual has a Medicare Supplement plan, it may cover the 20% copay.

When the beneficiary is admitted to the hosptial for a related condition within 3 days of the ER visit, they don’t pay the copay. Original Medicare processes the ER visit cost as part of the inpatient hospital stay.

Medicare Advantage

Although Medicare Advantage plans normally use provider networks for the enrollee’s care, the rules are very different during an emergency situation. When this is the case, Medicare Advantage plans must provie coverage for care even if the hospital or medical facility is out of the plan’s network. However, the copay amounts charged may differ from Original Medicare coverage. It is important to provide clients a complete picture of each plan they are considering. That includes emergency care copay amounts as well as all other coverage details and costs.

Medicare Advantage plans and the CMS consider an emergency, an untreated medical condition that could result in:

Serious jeopardy to the health of the individual. In the case of a pregnant woman, serious jeopardy to her health or the health of the unborn child. The definition also includes serious impairment or dysfunction of any organ or body part.

Some Medicare advantage plans don’t charge an ER copay if the enrollee is admitted to the hosptial within a 24 hours of the ER visit. When this happens, the MA/MAPD plan counts the ER visit as part of the hosptial stay. If the visit to the ER is later deemed not an actual emergency, MA plans cannot go back and require prior authorizatoion for the treatment.

Urgent care and Medicare Advantage plans

Instances where there is a non-emergent medical situation that requires immdiate attention, some MA/MAPD plans provide out-of-network coverage at urgent care facilities. This may happen if there is no in-network care available like on a weekend or if you are traveling outside the plan’s service area. Plan enrollees may have a copay similar to in-network urgent care.

Enrollees should check their plan’s summary of benefits or evidence of coverage for specific coverage provided by each plan. If you cannot locate these documents, enrollees can contact their insurance agent or call the member services number located on the back of their membership card.

Additional details

In general, Medicare provides coverage for ER visits that occur in the U.S.. It does not normally cover emergency medical care outside the U.S., although there are a few exeptions to this.

In some cases, Medicare supplements provide a lifetime limit of $50,000 for foreign travel emergencies. There are also Medicare Advantage plans that may provide a limited amount of coverage for foreign travel emergencies.

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Most Medicare agents have spent time explaining Medicare Part D deductibles to their clients. Many part D plans have a deductible. We will go over deductibles and how they impact the cost of your client’s prescription medications.

Medicare Part D

Part D (PDP) coverage is provided by private insurance companies that are approved by Medicare. Individuals enrolled in Medicare Part A and/or Part B who do not have other creditable coverage should enroll in a Part D plan. Even if the beneficiary does not currently take any prescription medications. Delaying part D enrollment for a period of 63 or more days causes the beneficiary to pay a late enrollment penalty.

If the beneficiary is Medicare eligible but has other creditable prescription coverage, they will not incur a penalty. The penalty lasts as long as the beneficiary has Part D coverage. Once a beneficiary is eligible for Medicare coverage, it is very important to enroll in a PDP plan.

Part D Deductibles

A deductible is the amount beneficiaries pay out-of-pocket for prescriptions before their Part D plan begins to share the costs. In other words, it is a threshold that is met before plan coverage kicks in. Once the enrollee pays the deductible, they generally pay a copay or coinsurance for prescription medications, with the PDP plan covering the remaining costs.

How Part D Deductibles Work

The specifics of Medicare Part D deductibles vary depending on the plan each individual chooses. Here are the key points clients should understand:

Annual Deductible

Most Part D plans have a deductible. The deductible is an annual amount, which can change each year. In 2024, the maximum deductible allowed by Medicare is $545. Some plans have lower deductibles, and a few may not even have a deductible at all. When this is the case, the coverage starts immediately.

Meeting the Deductible

The beneficiary must pay for the full cost of prescriptions until they pay the annual deductible amount. Once this threshold is met, the plan covers its portion of the prescription drug costs. The exact amount enrollees pay after meeting the deductible depends on each plan’s structure. Each plan has a specific co-pay or coinsurance amount depending on the plan’s formulary.

Formulary Tiers

Medicare Part D plans categorize drugs into different tiers. Each tier has a different cost associated with it, and generally, drugs on lower tiers (like generic medications) cost less than those on higher tiers (like brand-name or specialty drugs). The deductible may apply differently depending on the tier, and some plans might waive the deductible for drugs in certain tiers (usually tier 1 and sometimes tier 2 as well).

Changes in Part D coverage

It’s important to review PDP plan options each year during the Medicare Open Enrollment Period (October 15 to December 7). PDP plans can change their deductibles, drug formularies, and coverage, therefore it is imperative to ensure your client’s plan still meets their needs.

How deductibles impact plan cost

The deductible is one part of the overall cost of any Medicare Part D plan. Here are the ways it can impact the enrollees’ expenses:

Higher Deductibles

In most cases, plans with higher deductibles have lower monthly premiums. These plans may be a good choice for individuals who do not have prescription medications of whose medications are inexpensive (tier 1 or 2).

Lower Deductibles

Generally, plans with a low or no deductible have higher premiums. These plans can actually be more cost-effective for enrollees who require regular, expensive medications.

Managing the deductible

1. Compare plans: Our agents should use either Connecture or Sunfire to enter the client’s medication information and compare the costs of the Part D plans that are avialable. There are several things that contribute to the plan costs; deductibles, premiums, copays and coinsurance for each specific medication. Click here to watch a Sunfire demo on our YouTube channel.
2. Review all medications: Check the client’s current medications are covered by the plan’s formulary and what tier they are on. This can significantly affect out-of-pocket costs.
3. Apply for Extra Help: If the beneficiary has limited income and resources, they may qualify for Extra Help. This is also referred to as a Low-Income Subsidy, which helps pay for Medicare Part D premiums, deductibles, and co-pays.

Understanding Medicare Part D deductibles is an important part of managing prescription drug costs effectively. Agents should explain this to every PDP client and help them choose a plan that fits their healthcare coverage needs as well as their budget. An annual review of plan coverage allows clients to make any neccessary adjustments to their coverage and optimize coverage and minimize costs.

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