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Each year CMS provides the costs for Medicare. the 2025 Medicare costs include some expected adjustments to premiums, deductibles, and out-of-pocket expenses. This year the changes are based on inflation, healthcare demand, and legislative impacts. Below, we go over the anticipated cost structure, reasons behind the adjustments, and what it means for beneficiaries.

Hospital Insurance – Medicare Part A

Premium

Itis important to note; most people qualify for premium-free Part A due to their work history. However, those who do not qualify will pay an estimated $281 monthly for those with at least 30 quarters of work history, and $510 monthly for those with less than 30 quarters of work history.

Deductible

The Part A deductible is projected to increase to approximately $1,684. The Part A deductible is the cost a beneficiary pays if admitted into either the hospital or a skilled nursing facility.

Coinsurance Costs

Medicare Part A also has daily coinsurance for longer hospital stays. For 2025, beneficiaries can expect coinsurance rates for extended stays to go up to about $421 per day. This reflects the overall rate of inflation in hospital service costs.

Medical Insurance – Medicare Part B

Standard Premiums:

The Part B standard premium, in 2024 is $174.70. This amount will increase to about $185 per month. This increase primarily reflects higher outpatient and physician service costs.

Income-Related Adjustments:

Beneficiaries with higher incomes pay an Income-Related Monthly Adjustment Amount (IRMAA), which will also see a slight increase. These adjustments are based on yearly income, with the highest earners potentially paying over $600 per month in premiums.

Deductible:

The Part B deductible is expected to rise to about $257. Once the beneficiary meets the annual deductible, Medicare usually covers 80% of Medicare approved Part B services. The beneficiary is responsible for the remaining 20%.

Medicare Advantage Plans – Medicare Part C

Medicare Advantage plans (Part C) offer an alternative to original Medicare and include Part A, Part B, and in most cases, Part D (prescription drug) coverage. Private insurance companies offer these plans, and the pricing varies from $0 and go up from there.

Medicare Advantage plan, costs vary based on the plan and insurer, enrollees will also see some increases in premiums and out-of-pocket maximums. CMS caps out-of-pocket maximums. In 2025, they are expected to reach roughly $8,500. This could mean higher costs for enrollees with extensive health needs. There are many plans that will reduce extra benefits such as OTC, vision and dental to name a few.

Prescription Drug Plans – Medicare Part D

Premiums

Part D premiums for standalone prescription drug plans have an average cost of about $40, although this amount varies from $0 up to $150 per month. Overall, there are fewer plan choices available for 2025. Some plans have left the market, and some plans have consolidated their options. The actual plan cost depends on the specific plan and region.

Watch a quick YouTube video on the $2,000 drug cap

Deductibles and Coverage Gap

The maximum allowable deductible for Part D has increased to $590 for 2025. Additionally, the “donut hole” or coverage gap, where beneficiaries pay a greater share of drug costs, has been removed for 2025. Additionally, out-of-pocket drug costs are capped at $2,000. This may significantly reduce expenses for high-cost medications as long as they are on the plan’s formulary.

Why costs are increasing

Medicare cost adjustments reflect a variety of economic and healthcare factors:

Rising Healthcare Costs

Inflation in healthcare affects everything from hospital services to drug prices, driving up Medicare costs.

An Aging Population

As more people enroll in Medicare, especially those with high health needs, the overall program costs increase.

Legislative Changes

Recent legislation, such as the Inflation Reduction Act, introduced caps on Part D costs, in an attempt to reduce prescription drug expenses for seniors. This is causing many changes in the industry while insurance carriers figure out how to pay the billions of dollars this program will cost them. Unfortunately, insurance agents will lose commission on many plans and various plan costs will go up for many enrollees to make up for these changes.

What Can Beneficiaries Do

Use the help of a licensed Medicare agent to compare coverage options each year. A licensed agent can help find the coverage you want as well as a cost that is within your budget. Comparing plans each year is crucial as benefits and plan formularies change each year.

The Medicare cost increases for 2025 underscore the need for beneficiaries to review their coverage options and consider their healthcare needs. Beneficiaries should take advantage of Medicare’s annual open enrollment period to reassess and choose the best coverage.

Be sure to look into financial assistance programs such as MSP and Extra Help. These programs can make a huge difference with Part B and D costs.

Just like the other Medicare coverage options, there are specific rules for Medicare supplement changes. In general, beneficiaries enroll in a Medicare Supplement plan during their Medigap Open Enrollment Period.

Those who wish to apply for or change Medicare Supplement plans outside the Medigap OEP, may have to go through medical underwriting. However, there are some instances when beneficiaries qualify for a guaranteed issue right. This depends on which sate a beneficiary lives in.

Medigap open enrollment

The suggested time to enroll in a Medicare Supplement is during the Medigap OEP. This is a 6-month period that starts when the beneficiary enrolls in Medicare Part B and is at least 65 years of age. Those who enroll during this time do not have to go through medical underwriting. Underwriting is when an insurance carrier can deny coverage due to an underlying medical condition.

Keep in mind, the Medicare Supplement Open Enrollment is entirely different than the Medicare Open Enrollment that takes place annually from October 15th through December 7th.

During the Medicare AEP, beneficiaries can change or drop their Medicare Advantage (Part C) or PDP (Part D) plan. Be sure not to confuse this with the fall Medicare open enrollment period. This period runs from October 15 to December 7 every year. During fall open enrollment, you can enroll in, change, or drop your Medicare Part D prescription drug plan or your Medicare Advantage (Part C) plan. In many states, enrollees do not use this enrollment period to change Medicare Supplement plans.

Guaranteed issue rights

Those who miss their Medicare Supplement OEP may still qualify for guaranteed issue to enroll in or change their Medicare Supplement without underwriting. There are specific circumstances that offer enrollees guarantee issue rights. Review some circumstances that allow for GI rights below:

1. Enrollees who live in one of the four GI issue states (CT, NY, NH or MA).
2. Individuals who have Medicare A and B as well as employer coverage and are losing their employer plan.
3. Beneficiaries who enroll in a MA/MAPD or PACE program when they are first eligible and change their mind within the first year of coverage.
4. Those who have a MA/MAPD plan and are moving out of their plan’s service area.
5. The MA/MAPD plan the beneficiary enrolls in leaves the service area.
6. The Medicare Supplement provider ends coverage through no fault of the enrollee.
7. Enrollees who left a Medicare Supplement plan to try an MA/MAPD plan for the first time can re-enroll in a Medicare Supplement within the first year of trying a MA/MAPD plan.

Click here to learn more about GI rights for Medicare Supplement enrollment

What if you don’t qualify for a GI right

Those who do not qualify for a guaranteed issue right but still wish to change their Medicare Supplement plan may need to go through underwriting. If the beneficiary is healthy, most likely they will pass medical underwriting and receive approval for a new plan.

Beneficiaries with pre-existing conditions may be approved for a new plan although they may pay higher premiums. In some instances, the carrier may deny the beneficiary coverage.

Free look period

A free look period is a 30-day window that some Medicare Supplement enrollees can use to decide if they are happy with their new plan choice. This free look is available if a beneficiary changes from one Medicare Supplement to another.

What to remember when switching Supplements

When considering making a change in Medicare coverage, it is a good idea to get advice from a licensed Medicare agent. A licensed agent understands all your coverage options as well as your needs. They can sort out area plans and help guide you to making an informed decision.

Those who enroll in a new plan should not cancel their old plan until their new enrollment is confirmed. Beneficiaries may also want to pay for both plans for the first month in the event they decide not to keep the new plan.

Once the beneficiary is accepted into the new plan, they must cancel their current Medicare Supplement plan. If they do not, they will be charged for both plans. Those who are unsure about keeping the new plan can wait a month and pay for both to make sure they are happy with the new coverage.

Beneficiaries can request cancellations over the phone or in writing. Those who request the disenrollment over the phone should record a reference number for the call. It is also a good idea to make sure payment for the old plan does not continue.

Learn more about Medicare enrollment periods

More Rules for Medicare Supplement changes:

If a beneficiary moves to another state, they can remain in their current Medicare Supplement plan even if it is not offered in the new state. Although the new state may have its own Medicare Supplements that offer a better price point. A licensed Medicare agent can help find plan options in the new area.

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Understanding Medicare enrollment periods is crucial if you plan to offer Medicare plans to potential clients. It is also important to those becoming eligible for Medicare or hoping to make changes to an existing plan. We will break down the different Medicare enrollment periods and help beneficiaries make informed decisions.

Initial Enrollment Period (IEP)

The Initial Enrollment Period (IEP) is when a beneficiary first becomes eligible for Medicare. This period is a 7-month window, starting three months before the month you turn 65, including your birthday month, and ending three months after. For example, if your 65th birthday is in May, your IEP runs from February 1st to August 31st.

During your IEP, you can enroll in:

• Medicare Part A (Hospital Insurance)
• Medicare Part B (Medical Insurance)
• Medicare Advantage (Part C) or Part D (Prescription Drug Plan)

Individuals under 65 who qualify due to disability, have their own IEP. The IEP starts the 25th month of receiving Social Security Disability Insurance (SSDI).

Medicare General Enrollment Period (GEP)

If a beneficiary misses their Initial Enrollment Period, they can sign up for Medicare during the General Enrollment Period (GEP). The GEP runs from January 1st to March 31st each year. Coverage begins the 1st of the month after the beneficiary enrolls.

Although the GEP provides a second chance to get Medicare coverage, it’s important to note there may be late enrollment penalties for those who did not sign up for Medicare Part B when they were first eligible, unless they qualify for a Special Enrollment Period (SEP).

Medicare Annual Enrollment Period (AEP)

The Annual Enrollment Period (AEP) is a critical time for those already enrolled in Medicare to make changes to their plans. It occurs every year from October 15th to December 7th. During this period, you can:

• Switch from Original Medicare (Part A & B) to a Medicare Advantage (Part C) plan, or vice versa
• Change from one Medicare Advantage plan to another
• Add or drop a Part D (Prescription Drug Plan)
• Switch from one Part D plan to another

Click here for strategies for the 2025 AEP

Changes made during AEP will take effect on January 1st, 2025. This is the time to review your coverage, compare plans, and ensure that your healthcare needs will be met in the upcoming year.

Medicare Advantage Open Enrollment Period (MA OEP)

Those enrolled in a Medicare Advantage (Part C) plan, can use the Medicare Advantage Open Enrollment Period (MA OEP) to make a one-time change. This period runs from January 1st to March 31st annually. During the MA OEP, beneficiaries can make the following changes:

• Switch from one Medicare Advantage plan to another
• Disenroll from a Medicare Advantage plan and return to Original Medicare
• Join a Part D plan if you return to Original Medicare

Please note, beneficiaries cannot switch from Original Medicare to a Medicare Advantage plan during this period; changes are available only to those enrolled in MA/MAPD (Part C) plans.

Special Enrollment Periods (SEP)

Special Enrollment Periods (SEP) allow beneficiaries to enroll in or change Medicare plans outside of the usual enrollment periods as long as they qualify for them. A few reasons for SEP eligibility include:

• Loss of an employer-sponsored health plan
• Moving to a new location outside the current plan’s service area
• If the beneficiary gains eligibility for Medicaid or other financial assistance programs
• Disaster related emergencies may offer an SEP if an enrollment opportunity was missed
• Those who leave incarceration

SEPs vary in length and timing, depending on the reason for eligibility. For instance, those losing employer coverage, generally have an 8-month SEP starting from the month after their employment ends or group coverage ends (whichever comes first).

5-Star Special Enrollment Period

Both Medicare Advantage and Part D plans are rated on a 5-star scale by Medicare. The 5-star plans are the highest rated. If there is a 5-star plan available the beneficiaries’ service area, beneficiaries can enroll in it using the 5-Star Special Enrollment Period. This SEP allows a one-time switch to a 5-star plan at any point between December 8th and November 30th of the following year.

This election period provides an excellent opportunity to switch to a high-quality plan if there is one available in the beneficiaries’ area.

Key Tips for Navigating Enrollment in 2025

• Know the dates for each enrollment period to ensure an opportunity is not missed.
• Review the current coverage. During AEP, it is important to review your existing coverage and compare it with other available plans. Changes to premiums, coverage options, and provider networks may impact your decision.
• Use the beneficiaries should use all the tools available to them including Medicare agents Annual Notice of change ANOC, evidence of coverage and the Medicare Plan Finder tool on Medicare.gov. All these tools can help to compare plans, coverage, and costs.
• Understanding Medicare can be complex, Medicare agents are available to guide beneficiaries on available plans and options to best fit their needs. Reach out to a Medicare advisor or SHIP (State Health Insurance Assistance Program) counselor for guidance.

Agents, click here to fill out an online contract and join the team at Crowe

Understanding Medicare enrollment periods for 2025 is essential for making the right coverage is provided at the right time. Whether enrolling for the first time, looking to change, or there is a need for a special enrollment opportunity, it is important to stay informed about key dates and rules to help manage enrollment options effectively.

This year many agents are wondering what to do about lost PDP commissions. We are offering a few solutions to help supplement the loss of commissions. Please note there are still many opportunities to earn income in the field of Medicare sales.

The first thing you need to remember is that clients rely on your assistance to find the best plan options each year. Stay with us for a few suggestions to help raise your income.

Look at your client’s current PDP plan

Although your client’s current PDP plan may not be commissionable, it may still be the best option for them. Remember they have other plans with you, and you must make sure they know they can rely on your guidance. When clients see that you are willing to help them without a commission, it may lead to increased trust and a boost to your reputation. This can even lead to more client referrals in the long run.

Although we understand this will not pay your bills, if you do not want to provide assistance, someone else might. A smart agent knows, there are plenty of opportunities to assist clients with other commissionable products.

Watch a quick video on the prescription payment program

It is also important to know; some carriers are still paying commissions on PDP sales. Be sure you are contracted with a variety of carriers and plans in your service area. The best choice for the client may be a commissionable plan and, in that case, it’s a win for you both.

Click here to add carriers to your current Crowe contract or start a new contract request

Look at making a Medicare Supplement plan change

As you know, clients who are enrolled in a standalone PDP plan are usually enrolled in a Medicare Supplement plan. Many clients do not think about changing their Medicare Supplement coverage. The plan just renews each year and goes unnoticed.

In some instances, the Medicare Supplement plan carrier may have raised the plan cost over the year, and clients may not realize it. This provides an opportunity to find them a savings opportunity with the same coverage at a better rate from a competitive carrier. Keep in mind, some states may require underwriting to make a Medicare Supplement change. If you are lucky enough to be selling in a GI state, changing plans is as easy as writing an app.

A MAPD plan could be an option

Clients may want to give a Medicare Advantage plan a try. For some enrollees, this a great way to save money and still receive the protection of comprehensive medical coverage. MAPD plans are a very popular choice and can add to your bottom line. MAPD plans pay a generous commission rate for both new and renewal business.

Click here to learn about 2025 Medicare commissions

If you offer PDP plans, you already need to complete your AHIP, so there’s no reason not to add MAPD plans to your business.

Having a variety of product offerings help protect your income stream and gives clients a greater choice of coverage options.

Offer other needs-based products

Before you meet with each client, you should conduct a thorough needs-based assessment. This often leads to cross-selling opportunities. Clients may want to purchase insurance that fills a specific coverage gap. If you plan to discuss these coverage options, be sure your SOA includes ancillary products. In some cases, you may need to collect an additional SOA and make a subsequent appointment.

Ancillary products such as dental, vision, hospital indemnity, critical illness, cancer, heart attack and stroke or even long- and short-term care or life insurance are a few options. These products can provide necessary coverage for your clients and a supplement to your income as well. These products can more than make up for lost PDP commissions.

Learn more about why you should add ancillary products

For many agents, this year has been a bit frustrating and that is putting it mildly. The 2025 Medicare commissions have been the topic of many conversations. The commission amounts were up in the air for several months before the lawsuits that caused a federal judge to put a stay on a portion of the Medicare Final Rule that directly affects agent commission. As a result of the lawsuits, CMS issued some updates to 2025 Medicare Advantage and Part D broker commissions on July 18, 2024. The new amounts supersede those originally reported by CMS for 2025.

Medicare commission final update – YouTube Video

Important:

The additional administrative fee amounts of $100 for initial enrollments and $50 for renewals of both PDP and MA/MAPD Plans is no longer applicable. In other words, the additional money will not be added to commissions for 2025.

If the judge approves CMS Final rule at some point, the commission rates may increase by $100 for initial enrollments and $50 for renewals. This will be used as a one-time administrative fee to offset the loss of carrier marketing funds.

Although the increase we talked about in the previous paragraph will not be put in place, CMS has approved commission increases for both MA and PDP plan sales. This is due to a FMV (Fair Market Value) increase.

2025 Medicare Advantage commissions

Please keep in mind; the commission rates are not all the same and vary state to state.

In the states of CA and NJ, there will be an increase for initial commissions from $762 per member to $780 per member for 2025.  Renewal commissions for CA and NJ are going from $381 per member to $390 per member for 2025. 

For CT, DC and PA initial commissions will go from $689 per member for the first year to $705 per member.  Renewal commissions for CT, DC and PA will increase from $345 per member annually to $353 per member in 2025.

Puerto Rico as well as the U.S. Virgin Islands initial MA commissions will go from $418 per member annually to $428 per member for 2025.  The renewal commissions have increased from $209 a member for the year to $214 per member for the year.

For any state not listed above, initial MA commission amounts have increased from $611 per member annually to $626 per member for 2025. The commission rates for renewals have increased from $306 per member annually to $313 per member for 2025.

Join the Crowe team – fill out a quick online contract and get started!

PDP commissions for 2025:

In the case of PDP commissions, commission rates are the same in all states.

Initial commission rates for PDP plans have risen from $100 per member per year to $109 per member per year.  Commissions for PDP plan renewals have also increased from $50 per member each year to $55 per member each year.

Medicare Advantage Commissions 2025

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While the introduction of the Medicare drug cap in 2025 is a significant step towards making prescription medications more affordable, there are still some limitations and challenges to consider. Here are some key limitations of the Medicare drug cap:

The $2,000 Cap May Still Be Too High for Some Beneficiaries

• Although the $2,000 out-of-pocket cap is a substantial improvement, it might still be unaffordable for low-income beneficiaries who do not qualify for extra financial assistance. For individuals on a fixed income, $2,000 a year can still be a significant burden, particularly if they have other medical expenses.
• Some patients may still struggle with costs in the earlier part of the year, even if the cap limits their total annual expenses.

Only applies to Medicare Part D drugs

• The cap is specifically for Medicare Part D (stand-alone PDPs or MAPD plans) and does not cover drugs administered under Medicare Part B, such as certain cancer medications or infusion therapies. Beneficiaries who need these Part B drugs might still face high out-of-pocket expenses without the same cap protection.
• Many beneficiaries may not understand that the cap only applies to drugs that are on your plan’s formulary. If the client uses drugs that are not on their plan’s formulary, the cost of these drugs does not count towards the $2,000 cap. When the client uses a prescription drug that is off formulary, they should have their doctor request a formulary exception if possible.
• While the cap limits spending on prescriptions from a pharmacy, it doesn’t address the costs of drugs received during a hospital stay or in a doctor’s office, which can still be significant.

Potential for Premium Increases

• To offset the reduced out-of-pocket costs, some Part D plans might raise their monthly premiums. This means that, while beneficiaries may pay less at the pharmacy, they could see higher premiums throughout the year.
• Premium increases could make plans less affordable, especially for beneficiaries who use fewer medications and might not reach the $2,000 cap.

Does Not Impact Drug Prices Directly

• The $2,000 cap limits what beneficiaries pay out-of-pocket but does not control or reduce the actual prices of drugs set by pharmaceutical companies.
• Without addressing the root issue of high drug prices, there is still the potential for overall spending in Medicare Part D to rise, which could lead to higher premiums and other costs for beneficiaries over time.

Complex Smoothing Mechanism

• The smoothing mechanism introduced with the cap allows beneficiaries to spread out their out-of-pocket expenses throughout the year. While this can be helpful, it may also be complicated for some people to understand and use effectively.
• Beneficiaries might need assistance with opting into the smoothing mechanism and managing payments, and there could be administrative challenges that make it difficult for some to take full advantage of this feature.

Learn more about Medicare Smoothing

Watch a quick YouTube video on the Medicare prescription payment program

Limited Impact on Brand-Name and Specialty Drugs

• The cap does not change the formulary (list of covered drugs) or pricing tiers for plans that include Part D coverage. In other words, beneficiaries might still face high costs for certain brand-name and specialty drugs until they reach the $2,000 limit.
• Specialty drugs for conditions like cancer, multiple sclerosis, and rheumatoid arthritis are often very expensive, and while the cap limits total spending, beneficiaries may still need to pay large sums before they hit the cap, especially early in the year.

Variability Across Part D Plans

• All Part D plans vary in coverage, formularies, and cost-sharing structures. Beneficiaries may still face challenges finding a plan that covers all their medications at a reasonable cost, even with the new cap in place. Click her to learn why you should use a licensed Medicare agent
• Some plans may be better at managing costs than others, and beneficiaries will need to carefully compare their options during the Medicare AEP to ensure they get the best coverage for their needs.

Click here to learn why you should use a licensed Medicare agent.

Although the $2,000 out-of-pocket cap for Medicare Part D drugs is a step forward in making prescription drugs more affordable, it is not a perfect solution and does not address all the concerns associated with drug pricing and affordability.

When a client receives a denial for a Medicare claim, they may be frustrated. It is important to let them know they have options. If Medicare refuses to cover a service or item, or if there is a question about how much Medicare paid, clients need to understand the Medicare claim appeal process.

What Is a Medicare Appeal

A Medicare appeal is a formal request asking Medicare to review and reconsider a coverage or payment decision. You can appeal if:

• Medicare denies coverage for a service or item you think should be covered.
• You disagree with the amount Medicare paid for a service or item.
• Medicare decides to stop services you are currently receiving, like skilled nursing care or home health services.

Types of Medicare Appeals

The appeal process may differ depending on the type of Medicare you have. Here’s a breakdown:

1. Original Medicare (Part A and Part B) Appeals
2. Medicare Advantage (Part C) Appeals
3. Medicare Prescription Drug Plan (Part D) Appeals

Each type follows a specific set of rules, but the general steps remain similar across all parts.

Review the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)

Before beginning your appeal, review your Medicare Summary Notice (MSN) if you have Original Medicare or the Explanation of Benefits (EOB) if you have a Medicare Advantage or Part D plan. This document outlines what services Medicare paid for and what it denied. It will also tell you why the service was denied, which is critical information for your appeal.

Understand Your Appeal Rights

It’s important to understand your rights. Medicare guarantees that you can appeal their decisions, and there are five levels of appeals you can go through:

1. Redetermination by Medicare contractor
2. Reconsideration by a Qualified Independent Contractor (QIC)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council
5. Judicial review in Federal District Court

You don’t have to go through all five levels, but it’s good to know that you have multiple opportunities to present your case if needed.

Filing a Level 1 Appeal

The first step in the appeal process is filing a request for redetermination. Here’s how to do it:

1. Fill Out the Medicare Redetermination Request Form (Form CMS-20027): You can download this form online, or you can write a letter that includes your name, Medicare number, the specific service or item you’re appealing, and the reason you disagree with the decision.
2. Attach Supporting Documents: Include any documents that support your claim. This might include doctor’s notes, medical records, or a letter from your provider explaining why the service is necessary.
3. Send Your Appeal: The address for sending your appeal is on your MSN or EOB. You must submit your request within 120 days of the date on your MSN or EOB.

Waiting for a Response

Medicare contractors are required to respond to your appeal within 60 days. If they approve your appeal, Medicare will cover the service or pay the amount you requested. If your appeal is denied, you can proceed to the next level.

Level 2 Appeal – Reconsideration by a Qualified Independent Contractor (QIC)

If your redetermination is denied, you can request a reconsideration from a Qualified Independent Contractor (QIC). This must be done within 180 days of receiving the redetermination notice.

1. File a Request for Reconsideration (Form CMS-20033): Similar to the first appeal, you can download this form or write a letter. Clearly state why you believe the initial decision was wrong and include any additional documentation to support your claim.
2. Send the Request to the QIC: The address is included in the denial notice from your redetermination.

The QIC must respond to your request within 60 days. If they uphold the denial, you can proceed to the next level.

Level 3 Appeal – Administrative Law Judge (ALJ) Hearing

If your reconsideration request is denied, you can appeal to an Administrative Law Judge (ALJ). This option is available if the amount in question meets a minimum threshold (in 2025, this amount is approximately $180).

1. Request a Hearing: You can request a hearing within 60 days of receiving the QIC decision. You can also request to participate in person, by video conference, or by phone.
2. Prepare for Your Hearing: This is your chance to present your case directly to an impartial judge. You may wish to have an attorney or advocate to help represent your interests.

The ALJ will issue a decision within 90 days of your hearing request.

Level 4 Appeal – Medicare Appeals Council Review

If the ALJ denies your appeal, you can request a review by the Medicare Appeals Council. This must be done within 60 days of receiving the ALJ’s decision. The Appeals Council can either make a decision or send your case back to the ALJ for another review.

Level 5 Appeal – Federal District Court

The final level of appeal is a judicial review in Federal District Court. This is typically reserved for cases where a significant amount of money is at stake (in 2025, the threshold is approximately $1,850). You must file your case within 60 days of the Appeals Council decision.

Tips for a Successful Appeal

1. File Your Appeal On Time: Always pay attention to deadlines to avoid missing your opportunity to appeal.
2. Provide Detailed Information: Include all relevant documents, medical records, and a clear explanation of why you disagree with the decision.
3. Get Help If You Need It: You have the right to get help from a Medicare advocate or attorney. You can also contact your State Health Insurance Assistance Program (SHIP) for free assistance.

Click here to join the team of licensed Medicare agents at Crowe and Associates

Filing a Medicare claim appeal may seem daunting, but understanding the steps can make the process more manageable. Whether you’re challenging a coverage denial or disputing the amount paid, following these guidelines can help you navigate the appeal process more effectively.

It is important to remember to always keep copies of all documents and correspondence, and don’t hesitate to seek assistance if you need it.

Medicare scope of appointment rules

The Medicare SOA rules 2025 are put in place by CMS.  The SOA (scope of appointment) is a form clients/potential clients as well as agents must complete before meeting to discuss Medicare plans. The SOA is mandatory when discussing either Medicare Advantage or PDP plans. It is always a good idea to collect a SOA before client meetings to protect both agents and clients.

Watch a quick video on the scope of appointment rules for 2024

Verbal scope of appointment

During the pandemic, agents did not host in-person meetings to discuss coverage options.  At that time, many appointments took place over the phone.  That led to the use of recorded, verbal SOAs. 

Watch a video on Connecture & Sunfire updates for 2025

Both Connecture and Sunfire offer easy ways to collect client intake forms and include SOAs.

View the RetireFlo intake demo for Connecture 

Take a look at the BlazeSync intake form on Sunfire

SOA information

• If the client calls the agent (inbound call), the 48-hour rule does not apply.
• The scope is good for 12 months from the date it is signed.  You must complete the appointment within that time or obtain a new scope. The scope is still good if the call drops and the same agent calls the client back.
• If additional benefits are added to the discussion, a new scope is necessary.

How long is an SOA good

A scope of appointment is good for 12 months from the signature date. During the appointment, it is important to discuss only products that were agreed to and included in the scope.  If additional products are added, the beneficiary needs to sign a new scope.

If the client needs to sign a new SOA,  this restarts the 48-hour waiting period and may move your meeting date further out.  This rule applies to any product regulated by CMS.

Click here for a generic SOA

CMS guidelines

In order to be complaint with CMS, agents need to have their clients complete a SOA form. The CMS final rule went into effect September 30. 2023 and added changes to how agents collect an SOA.

The SOA rules apply to agents and brokers who discuss Medicare coverage options and plans.  The 48-hour rule was put in place so beneficiaries could avoid the high-pressure sales tactics some agents use.  The 48-hour period provides beneficiaries time to consult friends, relatives or anyone they like to research their options. This time also provides agents time to prepare for the discussion.

Agents are able to contact the beneficiary once the SOA is completed for up to 12 months. It is essentially permission to contact until the meeting takes place.  The beneficiary has the option to opt out annually.

Please note, if the beneficiary does not select a coverage option on the SOA, Medicare requires the agent to avoid discussing that option without a new SOA where the option is clearly selected.

Exceptions to the 48-hour rule

If the beneficiary is in the last four days of a valid election period, agents may collect a same-day SOA.

When the beneficiary walks into your office and initiates a conversation about coverage options, agents can take a same-day SOA.  This same rule applies to inbound call initiated by the beneficiary to the agent requesting advice.

How long do you need to keep a SOA

Agents must be able to access the SOA form for ten years. Clients have the right to request a copy anytime within that time frame without any issues.  The SOA can provide help in the event that an issue or dispute occurs.  The Scope is in place to protect the consumer, but it can also protect the agent.

What qualifies as preventative under Medicare and how do you ensure you take full advantage of these benefits? Because preventive care is an essential part of staying healthy and managing potential health risks before they become serious, Medicare recognizes the importance of preventive care and offers a range of services to help beneficiaries maintain their health.

What Is Preventive Care

Preventive care refers to medical services that aim to prevent illness, detect conditions early, or promote overall good health. These services can include screenings, vaccines, counseling, and much more. By focusing on prevention, Medicare helps beneficiaries proactively manage their health and reduce the need for more costly treatments in the future.

Click here to download a copy of a comprehensive list or covered preventative services

Medicare Coverage for Preventive Services

Medicare provides a wide array of preventive services under Part B (Medical Insurance). Many of these services are available to beneficiaries at no cost. These services may help detect health problems early when treatment is sometimes more effective and less expensive.

Some common types of preventive care Medicare covers:

Wellness Visits

Within the first 12 months a beneficiary enrolls in Medicare Part B, they are entitled to a “Welcome to Medicare” preventive visit. This one-time visit includes a review of your medical and family history, as well as basic measurements like height, weight, and blood pressure.

After your initial visit, Medicare covers an annual wellness visit each year. This can help create or update a personalized prevention plan. This plan can help beneficiaries stay on top of their health by identifying risk factors and setting health goals.

Vaccinations and Immunizations

Medicare covers vaccines that help prevent serious illnesses, including:

1. Flu Shot (Influenza): Covered once per flu season, typically every fall or winter.

2. Pneumococcal Vaccines: Medicare covers two different pneumococcal shots. The initial shot as well as a second shot a year later if appropriate.

3. Hepatitis B Vaccine: Available to those at medium or high risk for Hepatitis B.

4. COVID-19 Vaccines and Boosters: Medicare covers COVID-19 vaccines and booster shots as recommended by health authorities.

5. The Shingles Vaccine: This vaccine is administered in two doses. The second dose is given two to six months after the first. Medicare covers the cost of both doses.

Read more about Medicare coverage of vaccines

Screenings and Tests

Medicare offers a variety of preventive screenings and tests to help detect health issues early, including:

1. Mammograms: Medicare covers mammograms for the purpose of screening once every 12 months for women aged 40 and older. Medicare may also cover diagnostic mammograms if medically necessary.

2. Colon Cancer Screenings: Medicare covers multiple types of colon cancer screenings, including fecal occult blood tests, multi-target stool DNA tests (like Cologuard), flexible sigmoidoscopy, and colonoscopy. The frequency of these tests depends on the specific test and risk factors.

3. Bone Density Tests: Covered once every two years (or more often if medically necessary) for individuals at risk for osteoporosis.

4. Diabetes Screenings: Medicare covers up to two diabetes screenings per year for individuals at risk. This includes those with a history of high blood pressure, high cholesterol, obesity, or a family history of diabetes.

5. Cardiovascular Screenings: Medicare covers a screening blood test every five years to check for conditions like high cholesterol and triglyceride levels.

Cancer Screenings

Because early detection of cancer can lead to better treatment outcomes. Medicare covers:

1. Cervical and Vaginal Cancer Screenings: Medicare covers pap tests and pelvic exams are once every two years, or every year for women at high risk

2. Prostate Cancer Screenings: Annual prostate-specific antigen (PSA) tests and digital rectal exams for men aged 50 and older.

3. Lung Cancer Screenings: Low-dose CT scans are covered annually for individuals at high risk, particularly heavy smokers or those who have quit smoking within the past 15 years.

Cardiovascular Health

Medicare covers several services to help maintain cardiovascular health, including:

1.Cardiovascular Behavioral Therapy: This includes counseling on diet and exercise to help reduce the risk of heart disease.

2. Blood Pressure Screenings: These are typically part of your annual wellness visit.

Diabetes Prevention Program

The Medicare Diabetes Prevention Program offers lifestyle coaching and resources to help beneficiaries at risk for diabetes prevent the onset of the disease. The program is designed to encourage weight loss, healthy eating, and regular physical activity.

Mental Health and Wellness

Medicare also covers preventive services aimed at mental health, including:

1. Depression Screenings: Medicare includes an annual screening for depression as part of the yearly wellness visit.

2. Alcohol Misuse Counseling: Medicare covers counseling for beneficiaries who are screened and found to have alcohol misuse issues.

3. Smoking Cessation Programs: Medicare covers up to eight counseling sessions per year to help beneficiaries quit smoking.

Obesity Screening and Counseling

For individuals with a body mass index (BMI) of 30 or higher, Medicare covers counseling sessions to help promote weight loss and healthy living. This coverage includes regular face-to-face meetings with a healthcare provider.

Screenings for Infectious Diseases

Medicare also offers coverage for screenings to detect infectious diseases, including:

1. HIV Screenings: Covered once every 12 months, or more frequently for individuals at higher risk.

2. Hepatitis C Screenings: Covered once if born between 1945 and 1965, or annually for those at high risk.

3. Sexually Transmitted Infections (STIs): Medicare covers both screenings and counseling sessions annually for individuals at risk.

Make the Most of Medicare Preventive Services

1. Schedule an annual wellness visit: This visit is a great opportunity to discuss overall health and get a personalized prevention plan. It’s also a good time to make sure you’re up to date on all the preventive services you’re eligible for.
2. Know What Medicare Covers: Familiarize yourself with the list of preventive services Medicare covers and discuss these options with your healthcare provider. They can help determine which screenings and vaccines are appropriate for you.
3. Keep Track of When You’re Eligible: Medicare covers some services once a year or every few years. Make a note of when you’re eligible for your next screening or vaccination.

Preventive care is an important part of Medicare coverage and can help you stay healthier, detect potential problems early, and avoid costly treatments. Whether it’s a simple flu shot, a cancer screening, or an annual wellness visit, Medicare makes it easy for beneficiaries to access a wide range of preventive services. Understanding what’s covered and taking advantage of these benefits can play a key role in maintaining health and well-being.

If you need help choosing a Medicare plan, click here to learn why you should use a licensed Medicare agent

When it comes to Medicare Advantage plans, HMOs (Health Maintenance Organizations) are a popular option. Many Medicare carriers offer HMOs as a coverage option. They offer comprehensive healthcare coverage and focus on coordination and preventive care, however they come with advantages and limitations. Before suggesting enrollment in an HMO plan, it’s important for beneficiaries to understand Medicare HMOs Pros and cons. There are both benefits and drawbacks for those enrolling in a Medicare HMO plan.

What is an HMO

A Medicare HMO is a kind of Medicare Advantage plan (Part C). It provides coverage through a specific network of doctors, hospitals, and healthcare providers. Plan enrollees generally must receive care from in-network providers, except in emergency situations. Medicare HMOs typically include coverage for:

• Medicare Part A (hospital insurance)
• Medicare Part B (medical insurance)
• Medicare Part D (prescription drug coverage), if included in the plan
• Many plans include additional benefits such as dental, vision, hearing, fitness programs and OTC benefits.

Now let’s take a closer look at the pros and cons of Medicare HMOs.

Medicare HMO Pros

Lower Out-of-Pocket Costs

In some cases, Medicare HMOs have lower monthly premiums and out-of-pocket costs compared to Original Medicare (Parts A & B) or other types of Medicare Advantage plans, like PPOs.

Medicare HMO plans also set a maximum limit on out-of-pocket spending for covered services. Once you reach this limit, the plan covers 100% of the costs for covered services for the remainder of the year.

Comprehensive Coverage

Medicare HMOs often include benefits beyond what Original Medicare offers, such as dental, vision, hearing, fitness programs, and even OTC benefits and in some cases, rides to and from medical appointments. They also may include wellness services like acupuncture or chiropractic care.

Many Medicare HMO plans also include Part D prescription drug coverage. This makes it easier to manage all healthcare needs with one plan.

Coordinated Care

With Medicare HMOs, healthcare is often more coordinated. The enrollee’s PCP (primary care physician) acts as the point of contact for all healthcare needs. The PCP coordinates care and refers enrollees to in-network specialists as needed.

This coordinated approach may lead to better preventive care and management of chronic conditions, as all healthcare providers are working together and have access to your health records.

Focus on preventative care

Many Medicare HMO plans emphasize preventive care services, such as regular check-ups, screenings, and vaccinations. By encouraging preventive care, HMOs aim to keep enrollees healthier and reduce the need for more expensive treatments down the road.

Medicare HMO Cons

Limited Provider Network

The most significant downside to Medicare HMOs is the restricted provider network. In general enrollees must use doctors and specialists within the plan’s network, except in emergencies. HMO plans do not provide coverage for healthcare administered by out of network providers for non-emergency situations. If the potential enrollee has doctors that are not part of the HMO network, they will need to change providers.

Those who receive care outside the network without a referral or in a non-emergency situation, may be responsible for the entire cost of service. This can be a major inconvenience for those who prefer the freedom to see any doctor or specialist.

Referrals Required for Specialist Visits

If a specialist is needed, the enrollee must get a referral from their primary care physician. Although this can improve care coordination, it also adds an extra step that can delay receiving needed care. This may be true, especially if the beneficiary has multiple health concerns that require a specialist.

Some people opt not to join an HMO based on the need for referrals alone. The referral requirement may be too restrictive. Some Medicare beneficiaries may prefer PPO plans, that allow direct access to specialists without needing a PCP referral.

Not All Services Are Covered

Although Medicare HMOs often provide additional benefits, not all services are covered. For example, certain treatments, procedures, or medications may not be included in the plan’s formulary or service list, even if they are covered by other Medicare Advantage plans.

Regional Coverage Limitations

Medicare HMO networks are typically regional, in other words, the plan’s network of providers is centered around a specific area. Those who travel frequently or spend part of the year in a different location, may find it challenging to access in-network care outside the plan’s primary service area.

Some plans offer a limited network for non-emergency care while traveling, but it’s important to check the specifics of each HMO plan to understand how it handles out-of-area coverage.

Higher Costs If Out-of-Network

While Medicare HMOs generally have lower out-of-pocket costs, these savings only apply if enrollees stick to in-network providers. If they receive care outside the network (non-emergency and without a referral), the costs can add up quickly, and they will most likely be responsible for the entire cost of their care.

This can be a big disadvantage for those that require specialized care that isn’t available within the network or when traveling and need non-emergency medical attention.

Is an HMO the right coverage choice

Deciding whether a Medicare HMO is the best choice of coverage depends on healthcare needs, preferences, and budget. Here are a few things beneficiaries need to consider:

• Are they comfortable having a primary care physician coordinate their care?
• Do they mind getting referrals for specialist visits?
• Are all their doctors and healthcare providers part of the plan’s HMO network?
• Do they travel often and need flexibility in accessing care outside their local area?
• Are the costs and benefits offered in line with what you are looking for in a healthcare plan?

Medicare HMOs offer a range of benefits, including lower costs, comprehensive coverage, and coordinated care. However, the restricted network and referral requirements can be drawbacks for those who prefer more flexibility. Carefully reviewing the pros and cons can help determine if a Medicare HMO is the best choice for your client’s healthcare needs.

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