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Since the start of the introduction of the Affordable Care Act (ACA), there’s been a growing demand for professionals with the knowledge and skills to provide assistance to enrollees. ACA certification and training are one of the ways agents can stay up-to date on plan options and proper enrollment practices. This allows agents to help individuals make informed decisions and get access to healthcare.

Learn about our ACA sales contracting

Certifications agents need to offer ACA plans

Agents who want to offer ACA plans through the federal exchange site (healthcare.gov), must complete the FFM (Federally Facilitated Marketplace) certification. Although the ACA plans operate differently than Medicare does, the CMS also oversees ACA training. Agents complete this certification through CMS’ MLMS (Marketplace Learning Management System). One important thing to note; the FFM certification doesn’t cover insurance products sold through any of the state-based marketplaces.

FFM certification does not cover products sold in states that have their own state-based marketplace, The following states have state-based marketplaces that require agents to take their specific certifications:

CA – the state’s marketplace is Covered California

CO – the state’s marketplace is Connect for Health Colorado

CT – the state’s marketplace is Access Health CT

Please note: Access Health CT certification for 2024 for both Brokers and CACs is closing on July 31. Certification for Open Enrollment and for 2025 will start in September (Date TBA).  Those who certify before 7/31 will need to certify again in September for 2025.

DC – the state’s marketplace is DC Health Link

ID – the state’s marketplace is Your Health Idaho

KY – the state’s marketplace is Kynect

ME – the state’s marketplace is CoverME

MD – the state’s marketplace is Maryland Health Connection

MA – the state’s marketplace is Health Connector

MN – the state’s marketplace is Mnsure

NV – the state’s marketplace is Nevada Health Link

NJ – the state’s marketplace is Get Covered NJ

NM – the state’s marketplace is beWellnm

NY – the state’s marketplace is New York State of Health

PA – the state’s marketplace is Pennie

RI – the state’s marketplace is HealthSource RI

VT – the state’s marketplace is Vermont Health Connect

VA – the state’s marketplace is Virginia’s Insurance Marketplace

WA – the state’s marketplace is Washington Healthplanfinder

When do agents need to complete certifications

Certifications for states on the Federal Exchange as well as many state-based marketplaces must be completed annually. However, although some state-based training, such as NY, is required every 2 years. When there are changes to the ACA, CMS provides updated training modules.

Find out why you should offer ACA plans through Crowe:

Watch a Youtube video on ACA contracting with Crowe and Associates

Click here to view a demo of our ACA portal for agents and agencies

FFM certification

Agents who need to complete FFM (Federally Facilitated Marketplace) can access CMS’s Enterprise Portal to complete their FFM certs. If you don’t already have an account, you can create one. Once you are in the portal, go to choose “Add Application” and click on the FFM/Request for MLMS Training Access and follow the instructions.

The states that require FFM training: AL, AK, AZ, AR, DE, FL, GA, HI, IL, IN, IA, KS, KY, LA, ME, MI, MS, MO, MT, NE, NH, NM, NC, ND, OH, OK, OR, SC, SD, TN, TX, UT, VA, WV, WI and WY.

New ACA agents vs. returning agents

Agents who are new to the ACA market must take the entire training course while returning agents can take a shortened version of the course.  

New agents: click here for the CMS Marketplace training guide for 2024

Returning Agents: click here for CMS’ Marketplace training guide for 2024

The entire FFM certification consists of 10 training modules and four test; this takes a few hours to finish. A score of 70% or higher is required to pass the tests although agents who do not pass them can retake them. The refresher training only takes about an hour and a half to finish. There is no cost to the agent to take either course.

To check that CMS has updated your FFM cert status, use your NPN on the  Agent and Broker FFM Registration Completion List (RCL), just enter your NPN to check. Please note, it may take a few days for CMS to update the system.

FFM certification assistance

CMS provides technical assistance for agent who experience issues while completing the FFM course. Call the Marketplace service desk at 1-855-267-1515 for portal password resets and issues as well as registration and training questions. Agents can also contact the help desk via email at: FFMProducer-AssisterHelpDesk@cms.hhs.gov

Offering ACA plans is a great way to grow your business and assist more members of your community.

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Each year, Medicare agents have to take several tests and certifications before they can offer products to their clients. This year, our AHIP 2025 test tips will help get you up and running for a successful 2025.

Most MA/MAPD and PDP carriers require agents to pass the AHIP although, UHC does not require it, they have their own certification. The 2025 exam is available starting June 24th, 2024.  The 2025 AHIP covers any business you write for the rest of 2024 as well as through 2025.

Watch our YouTube video ” AHIP Test Tips 2025″

The AHIP is a CMS compliant course that is updated each year. This ensures the training is accurate as well as relevant to current CMS regulations.  For this reason, the AHIP 2025 test tips is a great tool for agents to use and complete the AHIP successfully.

Please note: In order to pass the exam, you must receive a grade of 90% to pass the exam. Agents have 2 hours to complete the exam and have 3 attempts to pass.  The exam consists of 50 multiple choice questions.  Those who do not pass after the third attempt, must pay for and retake the course.

Important; if you do not pass in the first 3 attempts, some carriers will not allow you to market their products for the year.

New agents who want to join the team at Crowe; click here for online contracting

If you are a Crowe agent who wants to add a carrier to your existing contract; click here

The cost for AHIP:

AHIP course and exam has a cost of $175. Agents can get a $50 discount by taking it through one of the major carrier’s sites (UHC, Aetna, Humana, etc.).  Any agent who is part of the Pinnacle financial team can also receive are a $50 discount as well.  All you need to do is go to pfsinsurance.com sign in, click on certifications tab and then the AEP Toolkit; from there you scroll down and see a link for the:

Click here for the Pinnacle AHIP discount

Please note; the 2025 AHIP is very similar to the 2024 AHIP

There are some new concepts and rules you need to be aware of.  Click on the link below to watch our video and learn more:

Here is what the AHIP covers:

The first part consists of 5 modules

• Medicare basics; fee-for-service and eligibility as well as benefits
• The different types of Medicare Advantage & prescription drug plans (Part D)
• Who is eligible and what is covered
• Nondiscrimination training
• Requirements for marketing and enrollment of Medicare Advantage as well as Part D/PDP plans

It is important to download each module once you are in it.  This is suggested to help you complete the test later.  If you took the 2024 AHIP, you only need to click through the slides on modules 4 & 5. We recommend clicking on modules 1-3 so you can download the content.  It is also not a bad idea to complete the practice tests at the end of ALL modules; many of those questions will be on the test.

Each module has a 20 question practice test at the end.  Pay attention to the practice questions; most of the test questions come from there.

Once you finish all modules and the exam,  do not forget to take the second part of the AHIP.

The second part covers fraud, waste, and abuse

• Learn how to spot fraud, waste, and abuse (FWA)
• Find out what the Medicare industry is doing to detect fraud
• What are the legal tools that combat FWA
• Understand the human as well as the financial cost of fraud waste and abuse
• Review general compliance requirements for Medicare Parts C and D fraud, waste, and abuse.
• Find out who commits fraud, waste, and abuse
• What are loophole and obligations to reporting fraud, waste and abuse

Once you successfully complete everything,  remember to download your AHIP certificate.  In some cases, carriers allow you to transmit your score directly from the AHIP site, but some require you to upload it into their dashboards yourself.

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If you are in Medicare sales, I am sure you have heard many uplines are adding ACA contracts. We will go over some reasons to add ACA health insurance sales to your business.

The Affordable Care Act (ACA) provides healthcare options for millions of Americans. Additionally, healthcare agents have an opportunity to make a difference in the lives of many individuals who need healthcare.

ACA Health Plans

The ACA introduced reforms to improve access to healthcare and enhance the quality of coverage. Health Insurance Marketplace and ACA-compliant health plans must adhere to standards, such as covering essential health care services and prohibiting discrimination based on pre-existing conditions. Subsidies and tax credits provided by the ACA, make health coverage more affordable for eligible individuals and families. To learn more about the ACA, visit healthcare.gov.

Reasons to add ACA health insurance sales

Providing access to necessary healthcare services

ACA health plans are crucial to many underserved individuals who otherwise do not receive the care they need. This is especially true in many low income communities. Agents helping individuals find affordable coverage options and the expansion of Medicaid eligibility, are both ways to ensure more people have access to medical care.

Protecting enrollees

Plans that comply with ACA regulations protect enrollees from the high cost of medical treatment and coverage denials. Selling these plans allows agents to advocate for their clients’ interests and guide them towards the best options for their coverage needs and budget.

Financial benefit

Agents who offer ACA health plans have the ability to earn commissions as well as various sales incentives. Because there are thousands of people who need coverage and the demand continues to grow, there is a real need for qualified professionals who can navigate the complexities of the insurance enrollment process.

If you are an agent who wants to get set up to offer ACA plans, click here to learn more

Certifications and Training:

Selling ACA health plans requires a solid understanding of healthcare regulations, insurance products, and customer needs. Although there are not as many certifications with the ACA as in the Medicare world, there are trainings and credentials required that vary by market and carrier. A few things agents need to have before they offer ACA plans:

1. Health Insurance License: Obtaining a state-issued health insurance license is a prerequisite for selling ACA health plans. This license demonstrates your understanding of insurance laws and regulations, as well as your commitment to ethical sales practices.
2. E&O Insurance: Agents need to have a valid certificate of E&O insurance to cover themselves for any mistakes they make that could prompt legal action by the client.
3. ACA Marketplace Training: The Centers for Medicare & Medicaid Services (CMS) offer training courses for agents and brokers seeking to assist consumers with Marketplace enrollment. These courses cover topics such as eligibility determination, plan selection, and enrollment assistance.

Watch a few YouTube videos on the ACA:

Find out what Crowe has to offer ACA agents and agencies

Learn more about ACA contracting

Watch a demo of what our ACA portal has to offer

Why offer ACA plans

For those agents looking to make a positive impact on people’s lives while building their business, selling ACA health plans could be the perfect fit for you. Medicare agents can use this opportunity to build a long-lasting relationship with your client. This will lead to a greater trust and knowledge of the client’s needs and wants for coverage and can lead to more Medicare leads in the long run.

By demonstrating competency and commitment to providing good service, agents can become a trusted resource in the community for various types of healthcare coverage.

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Crowe and Associates offers ACA agent sales contracting with a number of carriers. In addition, we have the ability to pay overrides to accommodate agencies with sub agents. All commissions are paid at full street level or above and the agent/agency owns the book of business. Our agent and agency partners can access a number of benefits including an agent specific admin portal, contracting support, enrollment portals and commission overrides.

Watch a 5 minute video review all our ACA program benefits for agents and agencies

ACA carriers available to contract

Agents have access to 20+ ACA carriers in all 50 states. Carriers include Anthem, Oscar, Ambetter, Aetna, Cigna, Molina, Medico, UHC, multiple BCBS organizations and a number of other carriers. We are adding additional carriers on an ongoing basis and are always open to inquiring with suggested carriers our partners need.

ACA Agent sales contracting

CLICK HERE FOR CONTRACTING

ACA Agent commissions

All agents are contracted to receive full street commission offered by each company. We do not reduce or keep any portion of an agents compensation. Agents will also receive 100% of any agent level bonus payments that may be available. (Not all carriers pay a bonus and some only do in certain states)

Agents will receive compensation directly from the carrier. Some carriers do not pay commissions directly to agents. When that is the case, we will pay the commissions and any applicable bonus payments to the agent.

Agents own the book of business and will continue to receive all commissions even if they go to another upline or move direct to a carrier

Carrier bonuses and bonuses specific to our agents

Agents will receive 100% of any carrier specific bonus programs. We also have bonus programs specific to agents with our agency. For example, we have an exclusive Anthem bonus that is available exlusively to our agents for 2024

Tier 1- 20 – 49 new members – $100 per member

Tier 2- 50+ new members – $150 per member

Agent and agency portal

All agents and agencies will have access to a personalized admin portal. The portal will provide acces to a number of features including: Applications, current book of business, commissions, contracting status, street commission amounts by carrier and state and training information and videos.

Agencies will have access to an admin version of the portal which will show production, contracting and commissions for all sub agents and agencies

Override payments for agents and agencies

We have the ability to pay agencies overrides above the street level commission. Overrides are paid on the same schedule as commission on a PMPM basis. Agencies looking for current override amounts should contact us to discuss what is available

Are you a Medicare agent? Learn about our programs and benefits for Medicare agents

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In general, Medicare is an affordable way for qualified individuals to receive healthcare coverage. However, there are some Medicare costs both agents and beneficiaries need to understand.

Plan Premiums

Premiums are a monthly fee the beneficiary pays for Medicare coverage.

Part A premiums

Although most beneficiaries do not pay a premium for Part A as long as they have worked for a Medicare-taxed job for a period of at least 10 years (40 quarters). In 2024, the premium for those who do not qualify for free Part A are between $278 to $505 monthly. The amount is based on the number of quarters the beneficiary or their spouse worked and paid Medicare taxes.

Part B premiums

Unlike Part A, almost everyone pays a Part B premium with the exception of those who meet certain income and asset levels and qualify for extra help. In general, most beneficiaries pay a standard amount for Part B. In 2024, the Part B premium amount is $174.70, although this amount may be adjusted according to each beneficiary’s income level. Those who earn over a specific thresh hold will pay an additional amount (IRMAA).

Part C (Medicare Advantage)premiums

Part C plans offer a variety of premiums, although many provide coverage for $0. The premium amount is based on the beneficiary’s location and plan availability. Please note; an IRMAA can also apply to a Medicare advantage plan if it includes Part D coverage.

Part D premiums

Similar to Part C premiums, the cost for Part D coverage varies by plan and coverage area. The national base beneficiary premium for 2024 is $34.70 per month. This is just a general premium amount CMS uses to calculate LEP penalties and not an actual premium amount. Premiums actually vary from $0 up to over $100 per month. Similar to Part B, individuals may pay a higher rate if they qualify for an IRMAA.

Find out how ancillary health insurance can cover some of the gaps in coverage.

IRMAA (Income Related Monthly Adjustment Amount)

An IRMAA is an additional amount CMS adds to the beneficiary’s monthly premium amount for Part B and Part D if their income exceeds the threshold amounts set by Medicare each year. The IRMAA is based on the individuals tax return from 2 years prior.

Click here to learn more about the income brackets for IRMAA 2024

LEP (Late enrollment penalty)

There are specific times beneficiaries must enroll in Medicare coverage. These are enrollment periods. If the beneficiary misses their enrollment period, they may pay an LEP. Medicare will add the penalty to their monthly premium.

Watch a YouTube video on OEPs, SEPs and Late Enrollments

Part A LEP

The LEP only applies to those who do not qualify for premium free Part A. Those who do not enroll on time have to pay a 10% higher Part A premium. Medicare applies the penalty for twice the number of years the beneficiary was eligible but didn’t enroll in Medicare. This means, if the beneficiary was eligible for Medicare but didn’t sign up for 3 years, they would pay an additional 10% for their Part A premium for 6 years.

Part B LEP

This penalty adds 10% times the number of years the beneficiary did not enroll in Medicare to the monthly premium and applies as long as the beneficiary has Medicare. In other words, if the beneficiary signs up for Medicare 3 years late, they pay 30% more for their premium. However, if they are actively working or have coverage through a spouse who is working, they can delay Part B enrollment without an LEP. Once they stop working, they qualify for an SEP and are eligible to enroll in Part B.

Part D and Part C plans that include drug coverage LEP

The LEP for Part D or Part C plans that include prescription drug coverage is 1% of the national base premium (this premium changes annually), multiplied by the number of months the beneficiary was eligible and did not enroll. This penalty is similar to the Part B penalty, because it lasts as long as the individual is enrolled in Medicare Part D. The federal government uses the standard rate (national base premium) to calculate Part D penalties not the individual’s actual plan premium. If the beneficiary delays Part D enrollment because they have another creditable drug plan, the penalty doesn’t apply to them.

Deductibles

Enrollees pay a deductible each year before their plan pays it’s portion of covered medical expenses.

While other Medicare plans have annual deductible, the deductible for Medicare Part A is $1,632 for each inpatient hospital stay. An individual could pay this deductible more than once a year depending on how many times they are admitted to the hospital. Each hospital admission counts as a new benefit period, unless the beneficiary is readmitted before the end of the benefit period.  Each benefit period ends 60 days after the enrollee is discharged.

Both Part B and Part D plans have one annual deductible. The Part B deductible is $240 in 2024. Although Part D deductibles vary according to plan, Medicare puts an annual limit on the maximum deductible allowed; in 2024 the maximum deductible is $545.

Copays and coinsurance

Both copays and coinsurance are fixed amounts the beneficiary pays for covered services or medications. These amounts apply after the beneficiary pays the deductible.

Part A coinsurance and copays

Once the beneficiary is in the hospital for over 60 days, they pay a coinsurance amount of $408 per day in 2024 for days 61 to 90. If the beneficiary is in the hospital for over 90 days, they can use some or all of their 60 lifetime reserve days. In 2024, each of these days cost $816. Each beneficiary qualifies for 60 reserve days for their lifetime. Once the beneficiary uses them all, they pay the entire remaining cost of their hospital stay.

Part A pays the first 20 days in a skilled nursing facility, once the beneficiary goes over the 20 days, they pay $204 per day for days 21-100. After day 100, the beneficiary is responsible for all costs. Many beneficiaries apply for Medicaid if they qualify, once they exhaust the Medicare coverage.

Part B coinsurance and copays

Part B normally provides coverage for 80% of approved Medicare expenses. That leaves the beneficiary with the remaining 20%. However, Medicare fully covers most preventative visits. Beneficiaries pay a higher co-insurance amount if their provider does not accept Medicare assignment.

Supplemental insurance can cover the 20% co-insurance cost and some of the copays with original Medicare. Click here to learn more.

Part C coinsurance and copays

Because Medicare Advantage plans work differently than Original Medicare, the coinsurance and copays work in a very different way. Medicare advantage plans use a specific network of providers who agree to accept the terms of payment. Each plan has it’s own co-pay amounts for doctor and specialist visits. Some plans provide coverage for visit to out of network providers at a higher cost share amount.

Each plan also has an out of pocket maximum. Once the beneficiary reaches this amount, the plan pays 100% of their approved medical costs.

Part D coinsurance and copays

Part D copays and coinsurance can vary quite a bit from one plan to another. That is why it is important to check all medications and cost sharing amounts before choosing a plan. In general, the cost for a prescription is higher for brand-name medications especially if they are on a higher tier in the plans formulary. If the beneficiary uses medications that are not on the formulary, they may have to pay the full costs of the medication.

There are other factors that decide the cost of medications such as the deductible, tier, the coverage gap and the catastrophic phase of coverage. Although there are changes coming in 2025 that will alter some of those cost shares. Plan enrollees should check their plan every year to ensure they are on the best plan to meet their coverage and budgetary needs.

Click here to learn about the Part D changes for 2025

Providers who don’t participate in Medicare

It is important to note: Not all doctors participate with Medicare. In some instances (rarely, but some), a provider has opted out of Medicare and does not accept Medicare as payment. This means the patient is responsible for paying any fees for service out of pocket.

Find out what Medicare Advantage plans don’t cover

As you can see, there are many potential costs associated with Medicare plans. We have not listed all of them. It is important to check the summary of benefits or evidence of coverage each year to ensure enrollment in the best plan option for each individual situation. A licensed Medicare agent can provide invaluable insights into plan choices and coverage options.

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There are a few different terms people use for supplemental Medicare insurance such as; Medigap, Medicare Supplement or Med Supp. Private insurance companies offer these health insurance policies to individuals who are eligible for Medicare coverage. In general, Medicare covers about 80 % of approved medical charges. Medicare supplement plans are designed to cover the 20% of approved medical charges not covered by Original Medicare. Essentially, Medicare supplement policies help reduce out-of-pocket costs. This ensures healthcare costs are predictable and manageable.

Why choose a Medicare Supplement

Although Original Medicare provides substantial coverage, it doesn’t cover everything. Here are some reasons to consider a Medicare Supplement:

Out-of-Pocket Costs: Original Medicare requires beneficiaries to pay for a percentage of their approved medical expenses. Because these can add up quickly, especially if you have frequent medical needs, a Medicare supplement pays these costs and saves enrollees money.

Find out more about Medicare costs

Foreign Travel: In general, Original Medicare doesn’t cover healthcare services outside the U.S.. Although some Medicare supplement plans provide coverage for emergency medical care during foreign travel.

Predictable Expenses: With a Medicare supplement plan, enrollees have predictable medical expenses, making it easier to manage their healthcare budget.

No Network Restrictions: Medicare supplement plans do not have network restrictions, this allows individuals to see any doctor or specialist that accepts Medicare.

Supplemental Medicare insurance plans

There are ten standard Medicare supplement plans, labeled A through N. Each plan provides a different level of coverage. The plan benefits of each plan letter are standardized, meaning Plan A from one insurance carrier offers the same benefits as Plan A from any other insurance carrier. These benefits are universal and don’t change by location. Although, plan availability varies by location. Insurance carriers do not offer all plans in every state.

Here is a basic over view of plan benefits:

• Plan A: This plan provides basic benefits, covers coinsurance and hospital costs (up to 365 additional days after Medicare benefit is used).
• Plan B: Benefits Include all the Plan A benefits plus it covers the Medicare Part A deductible.
• Plan C: Covers all of Plan B as well as skilled nursing facility care coinsurance and foreign travel emergency and also covers the Part B deductible.
• Plan D: This plan is similar to Plan C , although it does not cover the Part B deductible.
• Plan F: Provides comprehensive coverage, including the Part B deductible. Please note; this plan is no longer available to anyone who is eligible for Medicare after January 1, 2020.
• Plan G: These plans provide coverage very similar to Plan F although, they do not cover the Part B deductible.
• Plan K and L: Both these plans offer lower premiums but higher out-of-pocket costs, with coverage limits.
• Plan M and N: Plans provide a good cost-sharing option for specific benefits and lower plan premiums.

Click here to view a comparison chart of Medigap plans

Choosing the Right Plan

Selecting the right Medicare supplement plan requires careful consideration of both health needs and finances. Things to consider when choosing a plan. Please consider using the services of a licensed Medicare agent when making important health coverage decisions. This will ensure you have all the information you need to make an informed choice.

Assess Your Health Needs: Consider your current health status and any anticipated medical needs. If you require frequent medical services, a plan with more comprehensive coverage might be beneficial.

Budget Considerations: Evaluate your budget for monthly premiums versus out-of-pocket costs. Higher premiums generally mean lower out-of-pocket expenses.

Compare Plans: It is a good idea to use the services of a licensed Medicare agent when making important health coverage decisions. In most cases, they can access tools that can provide a comparison of the plans available in your area. This ensures you have all the information you need to make an informed choice.

Watch a YouTube video comparison of our quoting tools Sunfire vs Connecture

Check for Special Benefits: Some plans offer additional benefits, such as foreign travel emergency coverage or even a fitness benefit.

If you want to learn some of the differences between a Medicare Supplement and an Advantage plan, click here.

Enrollment Periods

The best time to buy a Medicare supplement policy is during your Open Enrollment Period, which starts the first month you have Medicare Part B and are 65 or older. During this period, you have a guaranteed issue right, meaning insurers cannot deny you coverage or charge higher premiums due to pre-existing conditions.

Always remember to meet with your agent each year to review your options and adjust your plan as your healthcare needs change.

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Because many people on Medicare require additional help at some point it is important to understand Medicare and home healthcare coverage. The main goal of home healthcare is help individuals recover from an illness or injury and regain independence.

Eligibility

In order for a beneficiary to qualify for home healthcare services under Medicare, the following criteria must be met:

1. A doctor or another licensed healthcare provider must have a face-to-face meeting with the beneficiary and certify that they require home health services.
2. The beneficiary must require part-time/intermittent skilled nursing care, physical therapy, occupational therapy or speech-language pathology services.
3. Patients must be homebound. In other words, it is difficult for them to leave the house without help due to their condition.
4. A Medicare certified home healthcare agency must provide the care.

Services Medicare covers

Once the eligibility criteria are met, Medicare covers many home health care services, including:

• Skilled Nursing Care: Provided on a part-time or intermittent basis.
• Therapy Services: Physical, occupational, and speech-language therapy to aid in recovery and rehabilitation.
• Home Health Aide Services: Assistance with personal care on a part-time basis if the patient is also receiving skilled care.
• Medical Social Services: Counseling and help finding community resources.
• Medical Supplies: Certain medical supplies like wound dressings.
• Durable Medical Equipment (DME): This includes equipment such as walkers or wheelchairs.

Services Medicare does not cover

• Full-time care: 24-hour-a-day care at home.
• Meals: Meals delivered to the home.
• Homemaker services: Medicare dose not cover services such as; shopping, cooking or cleaning if they are the only services needed.
• Personal care: If this is the only care required, Medicare will not pay a home health aide to provide basic personal care services such as bathing, dressing or using the bathroom (activities of daily living).

How to set up home healthcare services under Medicare

1. Make an appointment with your doctor or healthcare provider to go over your health needs and establish if home health care is a good choice.
2. Be sure you see your doctor face-to-face as required by Medicare.
3. Ask your doctor or insurance provider to help you find a Select a home health agency that is certified by Medicare.
4. Work with your doctor and the home health agency to develop a plan of care to fit your specific needs.

How Original Medicare covers home healthcare costs

In most cases, individuals enrolled in original Medicare pay nothing for covered home healthcare services. Although, there is a cost for DME durable medical equipment. In general, Medicare covers 80% of the approved amount while the individual is responsible for the remaining 20%.

Part A: Typically covers home health care services after the beneficiary has been in the hospital for a period of 3 days or more.

Part B: Covers home health services without the requirement of a prior hospital stay.

Watch a YouTube video the difference between Medicare Supplements and Medicare Advantage

Medicare Advantage Plans and Home Health Care

Medicare Advantage plans (Medicare Part C), are an alternative to Original Medicare. Private insurance companies that are approved by Medicare offer these plans. They must provide the same benefits as Medicare Part A and Part B. Many Medicare advantage plans also offer additional benefits that original Medicare does not cover, such as vision, dental, wellness programs, OTC as well as rides to medical appointments.

How Medicare Advantage plans cover home healthcare costs

Although Medicare Advantage plans must cover at least the same level of home health care services as Original Medicare, there are a few things you should know:

1. Network Restrictions: Unlike Original Medicare, Medicare Advantage plans often have network restrictions. Beneficiaries of most plans need to use home health agencies that are in the plan’s network.
2. Prior Authorization: Some Medicare Advantage plans require prior authorization for home health services. In other words, beneficiaries need approval from the plan before they receive certain services.
3. Additional Benefits: Many MA plans offer extra benefits beyond what Original Medicare provides. These could include additional support services, like caregiver support, home modifications, or wellness programs.
4. Cost Structure: Although Medicare Advantage plans must cover home health care at least as well as Original Medicare, the cost structure (copays, coinsurance, and deductibles) may be different. It’s important to understand your plan’s specific costs.

Find out how to cover the gaps left by Medicare advantage plans

Medicare’s home health care coverage can significantly benefit those who need medical care in the comfort of their own home. Understanding the eligibility criteria, the types of services covered, and how to initiate these services ensures that beneficiaries receive the appropriate care while minimizing out-of-pocket expenses.

Please note: before choosing a Medicare plan, it is best to consult a licensed healthcare agent to get accurate, personalized plan information.

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