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Many agents have asked this question year; What’s Different for AEP 2025. As we all know, Medicare AEP is a critical time for beneficiaries to review and adjust their health insurance coverage. The AEP takes place each year, from October 15th to December 7th. During this time, Medicare enrollees have the opportunity to make changes to their plans. This year’s AEP comes with some significant changes and updates that could impact coverage, costs, and benefits. Let’s go over some of the changes for Medicare AEP 2025.

Agents, click here to watch a quick YouTube video on strategies to manage this AEP

Medicare Part B Premiums and Deductibles

For 2025, the Medicare Part B premiums and deductibles will be adjusted as they have in previous years. The 2025 Part B premium is projected to increase about 5.9% to $185 per month. The deductible projection is approximately $257. This cost increase is largely due to inflation adjustments and increasing healthcare costs. Beneficiaries with higher incomes will also notice changes in their IRMAA (income-related monthly adjustment amounts). It is important for beneficiaries to review these updates and understand how they might impact their budget.

Changes to Part D drug plan benefits

The Medicare Prescription Drug (Part D) plans have made some significant changes. These changes will improve affordability for some beneficiaries:

• Removal of the Coverage Gap (Donut Hole) in 2025 there will be no coverage gap for PDP or MAPD plans.
• In 2025, catastrophic coverage begins once the beneficiary reaches the annual cap of $2,000 spent for prescriptions on their plan’s formulary.
• All plans that provide Medicare prescription drug coverage will be required to offer a payment plan option for beneficiaries. This will help enrollees spread out the cost of expensive prescriptions over the course of the plan year.
• The maximum deductible amount for PDP coverage will go up from $545 in 2024 to $590 in 2025.
• The $35 monthly insulin cost cap will continue in 2025. This ensures those with diabetes won’t pay more than $35 per month for insulin products covered under their Part D/MAPD plans.
• Necessary adult immunizations will be 100% covered by the plan providers. This includes flu shots, shingles shots and other adult immunizations.
• Some plan providers will no longer allow agents/brokers to sell their plans and plans will become non-commissionable.
• Some plan providers will leave the market all together while others will consolidate their product offerings.

Medicare Advantage Plans

• Many MA/MAPD plan providers will scale back benefits for 2025. This includes reductions in some dental and vision coverage amounts as well as a reduction in or removal of OTC benefits.
• Some MAPD plans will leave the market all together while others will reduce their market footprint. There are a few plans that will use this as an opportunity to expand their market area.
• The change in the number of available plans in certain areas may prove challenging for agents this year. It may be harder to find a plan that offers all the benefits your client wants as well as that their providers are in network with.

Expanded Coverage for Mental Health Services

There’s a growing recognition of the importance of mental health, and Medicare has responded by increasing its coverage for mental health services. More plans are now offering benefits like counseling, therapy sessions, and even virtual behavioral health services. This change addresses the rising mental health needs and to provides better access to care.

Medigap Policy Changes

While the main focus during AEP tends to be on Medicare Advantage and Part D plans, it’s important not to overlook Medigap (Medicare Supplement) policies. In some cases, AEP is a good time to see if clients are in the most cost-effective Medicare supplement available in their area. If another carrier offers the same plan at a lower cost, this is a great time to change plans.

Emphasis on Preventive Services

Medicare has increased focus on preventive care, encouraging beneficiaries to take advantage of annual wellness visits, vaccinations, and other screening services. Many preventive services are covered at no additional cost, depending on the plan. This makes it easier for enrollees to maintain their health without added expenses.

Key Takeaways for Beneficiaries:

• Review Current Coverage: Look at current Medicare Advantage, Medigap, and Part D plans, and see if the changes for 2025 affect coverage or costs.
• Compare Plan Options: This is the time to shop around. Use tools like the Medicare Plan Finder or a licensed Medicare agent to compare options and find the best plan for your needs and budget.
• Understand the New Benefits: Be sure to understand new benefits that may benefit you.

This year’s Medicare AEP brings many changes, as well as an attempt to make healthcare more affordable for some members.

It is always important to review your client’s plan options and provide assistance in navigating the changes. By staying informed, you can make the most of this year’s AEP and secure the healthcare coverage that best meets your client’s needs.

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You can’t turn on the TV and not hear about one weight loss drug or another. That has led to many people asking the question; what insurance covers Wegovy (GLP-1s)?

As of March 2024, the House Ways and Means Committee voted to pass the Treat and Reduce Obesity Act of 2024. This bill will allow Medicare Part D plans to cover GLP-1s (glucagon-like peptide agonists) to treat obesity when the enrollee is prescribed the drug before enrolling in Medicare. CMS approved Part D coverage of the weight loss drugs when prescribed for individuals with heart disease or strokes. The drugs are not approved for coverage when prescribed for weight loss alone.

Weight loss for prevention

The Ways and Means Committee suggested that covering drugs for weight loss alone makes sense as weight loss can prevent several illnesses triggered by obesity. By preventing obesity, medical treatment costs can be lower in the future.

It is a fact that obesity is a risk factor for several other medical conditions including diabetes, heart disease and even cancer. Many of these diseases are leading causes of mortality.

What is the cost of Obesity

It is estimated that obesity will cost the federal government over $4 trillion in the next 10 years due to rising healthcare costs for overweight Americans.

If this legislation does not pass, millions of people who are enrolling in Medicare lose coverage for potentially life-saving medications. These drugs have given many people back their lives and provided an opportunity for a healthier, active lifestyle.

If you need help enrolling in a Medicare plan; click here and learn why you should use a Medicare agent.

What if the legislation does pass

If the legislation passes and becomes a law, the already high demand for these drugs would grow even more. That in turn, could present greater supply issues than already exist. Manufacturers have imposed restrictions on off label use to try and deal with supply issues.

If this is legislation passes, the cost would be about $1.7 billion over the course of 10 years. This is the estimated cost only for drug coverage of those who had the prescription before they enrolled in Medicare. Some members want to be sure people do not lose this coverage just because they retire.

Future considerations

Some consider this bill as a step toward broader coverage. According to the Senate Health, Education, Labor and Pensions Committee, this could cause a significant impact on federal spending of about $400 billion annually if half of obese Americans took the drug.

Some committee members oppose the bill stating that; if even 10% of Medicare enrollees used the drug, it would cost approximately $27 billion each year. Although, other members would like to compel manufacturers to lower the cost of GLP-1s.

There are good arguments on both sides of this issue. We will all have to wait and see what happens next.

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Many people wonder how Medicare and ACA Marketplace insurance plans interact, whether they can keep their Marketplace coverage after enrolling in Medicare, and what happens to any premium tax credits they are receiving.

While Medicare and the ACA Marketplace both provide valuable health insurance options, they serve different populations and have distinct rules. Once you become eligible for Medicare, it’s generally best to transition from your ACA Marketplace plan to Medicare, as you will no longer be eligible for the premium tax credits that make ACA plans affordable.

What is Medicare and what it covers

Medicare is a federal health insurance program for people aged 65 and older as well as younger individuals with qualifying disabilities or end stage renal disease. Here is a quick look at some basic parts of Medicare:

• Part A (Hospital Insurance): Covers inpatient hospital care, skilled nursing facility care, hospice care, and some home health care. There are 4 main parts of Medicare
• Part B (Medical Insurance): Covers outpatient services like doctor visits, preventive services, and durable medical equipment.
• Part C (Medicare Advantage): An alternative to Original Medicare that offers all Part A and B benefits through private insurance companies. Many Part C plans also include Part D coverage and additional benefits like vision, dental, and prescription drugs.
• Part D (Prescription Drug Coverage): Helps cover the cost of covered prescription medications.

What Is the ACA Marketplace

The Affordable Care Act (ACA) created the Health Insurance Marketplace (also known as the Exchange) to provide health coverage to individuals and families who do not have access to employer-sponsored insurance or other forms of coverage, like Medicare or Medicaid. Through the Marketplace, people can purchase private health plans that meet ACA requirements, such as covering essential health benefits and preventive care.

One of the key benefits of the ACA Marketplace is the availability of premium tax credits and cost-sharing reductions for eligible individuals, which help lower the cost of monthly premiums and out-of-pocket expenses based on income.

Agents -Watch a quick YouTube video on how to get contracted to sell ACA plans

Can You Have Medicare and an ACA Marketplace Plan at the Same Time

It is not legal for any agent/broker to enroll a Medicare beneficiary in an ACA plan. This is true even if the beneficiary has Mediare Part A or Part B only.

Medicare Eligibility Automatically Ends ACA Premium Tax Credits:

When an individual becomes eligible for Medicare, they are no longer eligible for the premium tax credits that reduce the cost of ACA Marketplace plans. Those who recieve these subsidies, will lose them once they are eligible for Medicare, even if thye have not enrolled in Medicare yet.

Therefore, the cost for a Marketpalce plan for those who choose not to enroll in Medicare will pay a much higher price once they lose the premium tax credits. In most cases, Medicare will offer better or comparable coverage at a lower cost than a Marketplace plan without subsidies.

What Happens If You Delay Medicare Enrollment

Some people may want to delay Medicare enrollment because they prefer their ACA Marketplace coverage or want to keep the premium tax credits. However, delaying Medicare enrollment can result in financial penalties down the road.

Late Enrollment Penalties

• Part A: If you are eligible for premium-free Medicare Part A (based on your or your spouse’s work history), you should enroll as soon as you’re eligible because there’s no cost and it can help cover certain hospital expenses. If you don’t qualify for premium-free Part A and delay enrolling, you could face a late enrollment penalty if you decide to sign up later.
• Part B: Medicare Part B comes with a standard monthly premium, and if you don’t sign up when you’re first eligible, you may face a 10% penalty for each 12-month period you delay enrollment unless you have other creditable coverage (like employer-sponsored insurance).

In most cases, enrolling in Medicare as soon as you’re eligible helps you avoid penalties and ensures that you have comprehensive coverage.

Medicare vs. ACA Marketplace Plans Comparison

Transitioning from an ACA Marketplace Plan to Medicare

Individuals approaching Medicare eligibility who currently have an ACA Marketplace plan, must plan for the transition to Medicare. Here are a few things to remember:

Enroll in Medicare on Time

Most people are automatically enrolled in Medicare Part A and Part B if they’re receiving Social Security benefits. those who have delayed recipt of Social Security benefits will need to sign up during their initial enrollment period (IEP). The IEP starts three months before your 65th birthday and ends three months after.

Drop Your ACA Marketplace Plan

Once Medicare coverage starts, individuals are no longer eligible for Marketplace premium tax credits, therefore it’s important to cancel the ACA plan to avoid paying for unnecessary coverage.

Consider Additional Coverage

Depending on individual healthcare needs, enrollees may want to consider a Medicare Advantage plan (Part C) or a Medicare Supplement (Medigap) plan and a Part D plan for prescription drug coverage. These plans can provide coverage for out-of-pocket costs like deductibles, copays and coinsurance.

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The recent changes to Medicare SEPs for full, partial and LIS only members has caused some people to ask questions about Full vs Partial Dual Eligibility.

Watch a quick YouTube video on the Dual eligible SEP changes

Full Dual Eligibility

Individuals who are eligible for both Medicaid and Medicare are dual eligible. In other words, To have full dual eligibility, it means you qualify for full Medicaid benefits from your state as well as Medicare. Medicare covers most healthcare benefits, although Medicaid pays some out-of-pocket costs such as premiums, copays, coinsurance and deductibles as well as long-term care.

Those who are dual eligible may qualify for a DSNP plan. A DSNP plan is a kind of Medicare Advantage plan that provides additional benefits not provided by Medicare or Medicaid.

Partial Dual Eligibility

If an individual is Partial dual eligible, it means their income level qualifies them for an MSP (Medicare Savings Program). Each state manages the MSPs using their Medicaid program. MSPs cover some Medicare costs, such as Part A & Part B premiums. It is important to note; partial dual eligibility doesn’t provide the same medical benefit coverage as full Medicaid.

Some individuals who qualify as partial dual may also qualify for a DSNP (Dual Special Needs) plan. Although Medicare pays most of the health care benefits, partial duals are responsible for out-of-pocket costs.

How a MSP helps partial duals

When Medicare enrollees receive medical care, Medicare doesn’t cover the entire cost of the services. There is usually an amount that’s left over. This amount is the beneficiaries’ responsibility and is called cost share or out-of-pocket cost and includes copays, coinsurance premiums and deductibles. This amount is the responsibility of the member. This who are enrolled in an MSP may receive help from Medicaid in paying for some of those costs. The amount of help (or cost sharing) received from Medicaid depends on income level and assets (such as real estate).

The 4 types of partial dual eligibles

QMB – Qualified Medicare Beneficiary

Members who receive help at the QMB level receive helps paying for premiums for Medicare Parts A & B as well as some cost shares for deductibles, copays and coinsurance.

SLMB – Specified Low Income Medicare Beneficiary

The SLMB program provides help with Part B premiums only.

QI – Qualified Individual

Those at the QI level receive help with Part B premium payments, these individuals may have a higher income than SLMB recipients.

QDWI – Qualified Disabled and Working Individuals

Individuals on QDWI program receive helps paying Medicare Part A premiums (hospital insurance) . This level of help applies to disabled individuals who have returned to work and lost their premium-free Medicare Part A coverage.

The new SEPs for DNPs and LIS 2025 change when a dual eligible can leave or switch Medicare Advantage Plans. The Final Rule changed existing SEPs and put a new SEP for D-SNPs in place. Starting in 2025, dual eligible and LIS (Low-Income Subsidy) recipients can change their Medicare Advantage plan enrollment once per month. The rules vary according to the beneficiary’s level of help and include full-benefit dual eligibles, partial-benefit dual eligibles, and individuals enrolled in the LIS program but are not also enrolled in Medicaid (LIS-only).

Watch our recorded webinar on the changes to SEPs for DSNPS

SEP changes starting Jan 1, 2025:

1. The current SEP for Dual eligibles and LIS only individuals is available once per quarter. It lets individuals switch or disenroll from a Medicare Advantage plan. This SEP will be end as of Jan 1, 2025.
2. A new monthly SEP for all dual eligibles and LIS only individuals to disenroll from a MAPD plan and go back to Original Medicare and a stand-alone PDP plan.
3. There will be a new SEP for all Dual eligibles and LIS only individuals to switch PDP plan enrollment.
4. A new monthly SEP for full duals to enroll in an integrated and aligned D-SNP plan.

Monthly SEP for Dual Eligibles and LIS recipients

As of 2018, CMS put a quarterly SEP in place. This SEP allowed duals & LIS recipients to either enroll or disenroll in a MAPD or PDP plan. The enrollment or disenrollment goes into effect the first day of the following month after the enrollee makes a plan change during the first three quarters. If the change is made in the last quarter AEP from Oct 15 – Dec 7, the plan goes into effect as of January 1st of the following year.

CMS created a new SEP to replace the quarterly SEP. In 2025, dual eligible individuals and LIS-only individuals can change their MAPD and PDP enrollment one a month.  Those who qualify can switch to another standalone PDP plan or disenroll from a Medicare Advantage plan and go back to Original Medicare and a standalone PDP plan. Individuals cannot use this SEP to enroll in another Medicare Advantage plan.

Integrated SEP

The CMS Final Rule created an SEP that will help facilitate enrollment for Dual eligibles into integrated Medicare Advantage plans. Each month, Full-benefit dual eligibles have the option to enroll in, or switch between, integrated D-SNPs. This SEP is only available to full-benefit dual eligible individuals who wish to enroll in integrated plans. Doing this will align enrollment between their Medicare and Medicaid coverage.

Those eligible can use this SEP to enroll in either a FIDE SNP (Fully Integrated Dual Eligible Special Needs Plan); or a HIDE SNP (Highly Integrated Dually Eligible Special Needs Plan); or a D-SNP that is an AIP (Applicable Integrated Plan).

What you can’t do with the SEP

Individuals cannot use the SEP to enroll in a Coordination only D SNP that is not an AIP, or a standard Medicare Advantage plan. The goal CMS has with this AEP is to have dual eligible individuals enroll in aligned plans if they are available in their home state.

Who can use this SEP

This SEP is only available to full-benefit dual eligible individuals who have access to an integrated, aligned plan. The following individuals cannot use this SEP: partial-benefit dual eligible individuals, and Medicare-only individuals cannot use this SEP. Presently, partial-benefit dual eligible individuals and LIS-only individuals have a quarterly SEP they can use to switch Medicare Advantage Plans. Keep in mind, this SEP will end as of Jan 1. 2025.

What happens if a person uses both the monthly and integrated SEP in the same month?

If an individual attempts to use the monthly SEP and the integrated SEP the same month, the SEP used last in will be effective. For example, Ms. Smith uses the monthly SEP to go back to Original Medicare on March 10th and on March 16th, she uses the integrated SEP to enroll in an Integrated Plan A, the integrated SEP is last used, and Ms. Smith will be enrolled into Integrated Plan A on April 1st.

SEP Changes for DSNPS & LIS 2025

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The NABIP certification for 2025 is a comprehensive online program designed specifically for health insurance agents and brokers. This certification provides the CMS required training that agents need to sell Medicare Advantage. Many insurance carriers now accept NABIP as a source for annual certifications. Please keep in mind, some carriers do not accept this training and prefer the AHIP.

NABIP

NABIP is The National Association of Benefits and Insurance Professionals. It was formerly known as NAHU, the National Association of Health Underwriters. This professional organization represents individuals and companies in the health insurance industry. NABIP provides an important role in the industry through education, advocacy, and networking opportunities. This helps members serve clients and achieve success in their careers.

This cost for the course is $100 annually and provides comprehensive instruction on Medicare Advantage plan rules and marketing.

NABIP’s certification course meets CMS requirements and provides veteran agents a quicker option for completion. The course consists of basic Medicare, Medicare Advantage, and fraud, waste, and abuse training. 

CE Credits

Continuing education (CE) credits are included in your purchase at no additional charge. NAHU has filed their Medicare Advantage certification for CE credits in all 50 states. Please check your state for CE credit approval status before registration. Once the certifications are complete, agents have access to the NABIP logo they can apply to their website, social media and email. This lets people know you are a certified professional and provides a level of credibility.

Plan sponsors who accept NABIP’s Medicare Advantage Certification continues to grow. To view a list of carriers who currently recognize this certification in 2025, Click here.

To learn more about NABIP and access the certifications; Click here. If you need assistance or have questions, contact; Student Services Helpdesk either by phone or email at: 844-257-0990 professionaldevelopment@nabip.org

NABIP Medicare Advantage Certifications – what they cover:

There are 3 modules in the NABIP Medicare Advantage certifications. The consist of:

1. The basics of Medicare
2. Marketing guidelines for Medicare
3. Fraud, Waste & Abuse

NABIP vs AHIP

Both NABIP & AHIP certifications fulfill CMS’s Medicare compliance training requirements. Although, there are differences between the two programs. For instance, the NABIP certification course has a cost of $100, the AHIP training course has a cost of $175.

In order to pass the NABIP course, agents must receive a grade of 85% to pass. AHIP requires a score of 90% to pass the course.

NABIP gives agents 6 attempts to pass the test at no additional charge, while AHIP allows only 3 attempts at no charge.

Click here to watch a YouTube video of AHIP 2025 test tips

Additionally, NABIP provides 8 CE credits, free of charge, while AHIP provides CE credits only after an additional payment. NABIP also offers additional content that is decided using input provided by the Medicare broker community.

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Please note:

All carriers do not currently accept the NABIP certification. Agents who use NABIP as a certification tool, may also need to complete the AHIP in order to be ready to sell with all Medicare carriers.

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When it comes to helping clients choose a Medicare plan, there are many types of plans to consider. Those clients leaning towards a Medicare Advantage plan need to understand Medicare PPO vs. Medicare HMO plans. Although both plan types provide comprehensive coverage, they differ in many ways including how the enrollee’s healthcare is managed, costs for care flexibility of providers used. In this blog, we’ll go over some benefits of PPO and HMO plans to help determine which option may suit your client’s needs best.

Medicare PPO Plans

Provider choice flexibility

Although Medicare PPO plans have a network of preferred providers, plan enrollees may opt to receive care from an out of network provider for a higher fee. PPOs give the enrollee the freedom to see any doctor or specialist they choose, without the need for a referral.

Costs

In general, PPO plans may have similar cost share amounts compared to HMO plans. These amounts vary by plan type, carrier and service area. However, PPO plans offer lower out-of-pocket costs if enrollees stay within the network. The flexibility to see out-of-network providers comes with the potential to pay higher out-of-pocket amounts for those services.

PCP (Primary Care Physician) requirement

Unlike HMO plans, PPO plan enrollees are not usually required to choose a primary care physician (PCP). They do not need to get a referral from a PCP before seeing a specialists or other healthcare provider.

Medicare HMO Plans

Restrictions

In general, the choice of providers in a Medicare HMO plan is more restrictive. Enrollees are required to use healthcare providers and facilities within the plan’s network, unless it is emergency situation. Those who opt to receive care from an out-of-network provider, may have to pay out-of-pocket for the full cost of services.

Lower Costs

HMO plans often have lower out-of-pocket costs compared to PPO plans. Although, the network of providers is limited, and enrollees must stay within the network to keep low costs.

PCP (Primary Care Physician) Requirement

HMO plans require enrollees to choose a primary care physician. Their PCP will manage their healthcare needs. If the enrollee wants to see a specialist, they must first obtain a referral from their PCP. This helps manage and coordinate care effectively but may be inconvenient for some people.

Agents watch a quick YouTube video on strategies to manage the 2025 AEP

How to choose

The best choice differs from one person to the next and is based on individual healthcare needs and preferences. Both plan types have advantages and disadvantages.

Consider a PPO Plan if:

1. The enrollee wants the flexibility to see any doctor or specialist without a referral.
2. Higher costs are less important than the ability to choose any provider
3. There may be a desire for out of network services, even at a higher rate.

Consider an HMO Plan if:

1. Enrollees are willing to use a specific network of providers.
2. They like the idea of a PCP managing and coordinating their healthcare needs.
3. The enrollee does not see the need to use out-of-network providers and does not mind network restrictions.

Agents must consider the clients’ needs, budget and service area in order to find the best fit for their client.

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