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When helping clients plan for their healthcare coverage needs, it’s important to discuss not just what Medicare does cover, but also what it doesn’t. Understanding these gaps can help clients avoid unexpected expenses and make informed decisions about supplemental insurance options. Let’s take a closer look at some of what Medicare won’t cover.

Long-Term Care

One of the biggest misconceptions about Medicare is that it covers long-term care, like nursing home stays or in-home care for chronic conditions. In reality, Medicare only covers short-term skilled nursing care under specific conditions. Clients may need separate long-term care insurance or other financial strategies to cover these considerable costs. Learn about short-term care vs long-term care plans.

Most Dental Care

Routine dental services such as cleanings, fillings, tooth extractions, dentures, and dental implants are generally not covered by Medicare. If dental care is important to your client, you should explore standalone dental insurance or Medicare Advantage plans that offer dental benefits.

Learn about stand-alone dental coverage available in all 50 states

Vision Care

Medicare does not cover routine eye exams for glasses or contacts. It will, however, cover eye exams related to medical conditions like glaucoma or cataracts. Clients needing regular vision care might consider standalone vision insurance or a Medicare Advantage plan with vision coverage.

Hearing Aids and Exams

Original Medicare doesn’t cover hearing aids or exams for fitting them, which can be a significant expense. Some Medicare Advantage plans offer hearing benefits, so this is worth exploring based on client needs.

Routine Foot Care

Routine foot care, such as treatment for corns, calluses, or nail trimming, is not covered unless it’s deemed medically necessary due to a condition like diabetes.

Overseas Health Care

Most care received outside the United States is not covered by Medicare. For clients who plan to travel internationally, consider recommending a Medigap plan that includes foreign travel emergency coverage or a separate travel insurance policy.

Elective Surgery

Medicare won’t cover elective cosmetic surgeries, such as facelifts or liposuction. It will however, cover surgeries that deemed medically necessary, such as reconstructive surgery after an accident or some forms of cancer.

Key Takeaways for Agents

This is just an idea of what is not covered by Medicare, for a complete lists click here.

• Discuss Supplement Options: Educate clients on the benefits of Medigap (Medicare Supplement) plans, Medicare Advantage plans, or standalone insurance options for things like dental, vison & hearing or other ancillary products to fill the coverage gaps.
• Tailor Recommendations: Understand each client’s lifestyle and health priorities to recommend the right supplemental coverage.
• Plan for the Unexpected: Help clients build a financial plan that anticipates out-of-pocket healthcare expenses.

Being proactive about Medicare’s limitations helps clients better prepare for retirement. As agents, we can offer tremendous value by guiding clients through their options to ensure they have the comprehensive healthcare coverage they need.

To get some tips to maintain your book of business; click here

When talking to clients about preparing for unexpected expenses in retirement, long-term care often takes center stage. In many cases clients should consider short-term care. Short-term care insurance is an underutilized but very valuable product that can offer peace of mind and financial protection for clients facing temporary health challenges.

Here’s a breakdown of why agents should consider introducing short-term care plans as part of a well-rounded retirement strategy.

Short-Term Care Insurance

Short-term care insurance is designed to cover care and services for a limited time, usually up to 12 months. It can be used for home health care, assisted living, or skilled nursing facility services following an illness, injury, or surgery. Unlike long-term care insurance, it is more affordable and easier to qualify for.

Benefits of Short-Term Care Plans

Affordable Premiums

Short-term care plans typically have lower premiums than traditional long-term care insurance, making them accessible for clients with tighter budgets or those who may not qualify for long-term care due to age or health issues.

Simplified Underwriting

Quick Benefit Triggers

These plans often come with simplified underwriting, which means no medical exams; just a basic health questionnaire. This is ideal for clients who may not qualify for more comprehensive long-term care plans.

Short-term care plans generally begin paying out benefits much sooner than long-term care insurance, often with little or no elimination period. This is crucial for clients needing immediate care after an unexpected health event.

Watch a quick YouTube video of why you should offer ancillary products with Medicare sales

Flexibility of Care Settings

Clients can use their benefits in a variety of settings, including at home or in a facility. This provides them greater choice and comfort during their recovery.

Bridges the Gap

For clients waiting for long-term care coverage to start or who may have gaps in their existing coverage (like Medicare), short-term care can provide vital coverage during this period.

When to Recommend Short-Term Care Insurance

• Clients nearing or already retired who don’t qualify for long-term care insurance may consider short-term coverage.
• Those concerned about high out-of-pocket expenses for short recovery periods.
• Individuals looking to supplement Medicare or a high-deductible health plan coverage.
• Clients who want a cost-effective safety net without having to commit to a more expensive long-term care policy.

Thoughts for Agents

Short-term care insurance isn’t just a backup plan; it’s a proactive solution. As agents, offering this option shows clients you understand all their retirement healthcare coverage needs. It’s also a great way to differentiate your services by providing options that are both practical and affordable.

As Medicare agents, our clients are often looking for stability and security, especially when they are planning for retirement. Annuities are a powerful tool in our toolbox to help meet those needs. In this post, we’ll break down the annuities, explore the different types available, and offer insights on how to best position annuities for our clients. Hopefully, this will help with understanding the basics of annuities.

Annuities

An annuity is a contract between an individual and an insurance company, designed primarily to provide a steady stream of income, often during retirement. Clients pay either a lump sum or a series of payments, and in return, the insurance company provides scheduled payments either immediately or at a future date.

In addition to providing income, annuities offer tax-deferred income growth, which can be a significant selling point for clients who want to maximize their retirement savings.

Types of Annuities

Understanding the different types of annuities allows agents to tailor recommendations based on the individual goals of each client.

Fixed Annuities

Fixed annuities guarantee a specific rate of return and offer predictable payments. They are ideal for clients who prioritize stability and steady income without market risk.

Variable Annuities

Variable annuities allow clients to invest in various market-based options, like mutual funds. This product is suited for clients willing to accept more risk for the possibility of higher returns.

Indexed Annuities

Indexed annuities provide returns linked to a market index, like the S&P 500, while protecting against market losses. They are a middle-ground option for clients seeking some growth potential without full market exposure.

Immediate Annuities

Clients needing immediate income can benefit from immediate annuities, which begin payouts typically within a year of purchase. They are a strong fit for retirees who want to turn a lump sum into a guaranteed income stream right away.

Deferred Annuities

Deferred annuities allow clients to invest now and receive payments later, often during retirement. This option is attractive for those looking to grow their money tax-deferred over time.

Learn the value of cross selling products to your clients

Key Considerations When Presenting Annuities

• Fees and Expenses: We must ensure clients understand all associated costs, particularly with variable and indexed annuities.
• Surrender Charges: It’s essential to educate clients about penalties for early withdrawals.
• Company Strength: Recommend products from insurers with strong financial ratings to ensure reliability.
• Client Goals: Align annuity recommendations with the client’s broader retirement and financial goals.

As agents, we have the opportunity to provide our clients with solutions that offer peace of mind and financial security. Annuities can be a cornerstone of a well-rounded retirement strategy when matched appropriately with client needs and objectives.

Click here to watch a quick YouTube video on Annuity basics.

If you’re interested in brushing up on your annuity product knowledge or exploring strategies to better serve your clients, let’s connect! Please give the Pinnacle Annuity Team a call 800-772-6881 x6003 for additional information. Helping clients achieve financial confidence is what we do best.

Medicare helps millions of Americans 65 and over and those with qualified disabilities and ESRD access the healthcare they need. Unfortunately, it also attracts scammers who are looking to take advantage of unsuspecting beneficiaries. One of the most common tools scammers use is the phone. In this post, we discuss some of the most common Medicare phone scams and how to avoid them.

Anyone on Medicare or helping someone who is should know the red flags to help guard against fraud.

Common Medicare Phone Scams

“We’re issuing you a new Medicare card”

Scammers may call claiming that Medicare is sending out new cards (often with a chip or updated feature), and that they just need to “verify” your Medicare number or Social Security number.

In reality, some individuals were issued new Medicare cards but no one called beneficiaries on the phone; click here for more details.

Important: Medicare will never call you to ask for personal information out of the blue. If there were truly a new card, you’d get a letter or notice in the mail.

“You qualify for free medical equipment”

This one often targets people with diabetes or chronic pain. The caller might offer free back braces, knee braces, or glucose monitors in exchange for your Medicare number.

In reality: These “free” items are often billed to Medicare fraudulently. You could end up responsible for the cost or even flagged for abuse of your benefits.

Fake Medicare representatives

Some scammers impersonate Medicare employees or contractors and use urgent language to scare you: “Your benefits will be cut off” or “We detected suspicious activity.”

Remember: Medicare officials do not call unsolicited to threaten or pressure you. Real communication will be by mail, and you can verify legitimacy before responding.

COVID-19 test scams

During the pandemic (and even now), scammers offered free COVID tests or vaccines in exchange for your Medicare info. These have since evolved into offers for “new virus screenings” or “preventive health checkups.”

Keep in mind: While COVID tests and vaccines are covered by Medicare, they do not require phone enrollment or any payment up front.

“We can lower your Medicare premiums”

Some calls promise to reduce your monthly Medicare costs or enroll you in a “better” plan; usually with limited information and a high-pressure sales pitch. Learn more about these Medicare scams.

Important: Legitimate plan changes should go through licensed agents or official Medicare channels, not someone who refuses to send information in writing or insists on getting personal data over the phone.

How to Protect Yourself

• Hang up on unsolicited calls. If it feels fishy, it probably is.
• Never give out your Medicare number, Social Security number, or banking information over the phone; unless you initiated the call to a trusted number.
• Contact your Medicare agent or use the 1-800-MEDICARE number or visit medicare.gov if you have questions or are unsure about something.
• Check your Medicare Summary Notices (MSNs) regularly to spot unfamiliar charges.
• Report scams to Medicare at 1-800-MEDICARE or to the FTC at reportfraud.ftc.gov.

Remember

Scammers are smart and persistent but with a little awareness, you can stay one step ahead of them. Medicare will never call you out of the blue to ask for your information, and anything that sounds too good to be true usually is.

Know the red flags, trust your instincts, and share this information with friends and loved ones. A quick heads-up could prevent someone you care about from falling victim to fraud.

In the ever-evolving world of health and senior insurance, agents are always looking for products that provide real value to their clients and also add revenue to their business. We will go over some reasons selling short term care plans is a good way to helpclients and bring in revenue.

One of the most underutilized tools in your arsenal might just be Short-Term Care (STC) insurance. If you’re not already talking to your clients about STC, here’s why now is the time to start.

Short Term Care Insurance

Short-Term Care (or Recovery Care) insurance is designed to help cover care costs for a limited time, usually up to 12 months in settings like:

• Nursing homes
• Assisted living facilities
• Home health care
• Adult day care

It bridges the gap between Medicare (or traditional health insurance) and long-term care insurance, offering a more affordable and accessible solution.

Learn the key differences between long term and short term care insurance.

Why Agents Should Sell It

Fills a Coverage Gap

Medicare doesn’t cover long-term custodial care, and many clients either can’t afford or don’t qualify for traditional long-term care insurance.

STC provides a financial safety net during short-term recovery periods after surgery, illness, or injury without the high cost or strict underwriting of long-term care policies.

Easier to Qualify For

STC plans often have simplified underwriting, making them ideal for:

• Older clients (even up to age 89, depending on the carrier)
• Those with health conditions that disqualify them from LTC policies
• People who’ve waited “too long” to consider long-term planning

For clients that do not qualify for long-term care, STC might be their next best option.

Affordable for Clients

Many STC policies cost significantly less than traditional long-term care. That makes it easier for clients with various income levels to protect their retirement savings without breaking the bank.

Additionally; plans can be customized to fit a wide range of budgets.

Flexible Benefits

STC plans typically offer:

• Daily benefit amounts (e.g., $100–$300/day)
• Benefit periods (e.g., 90, 180, or 360 days)
• Optional riders like home health care or prescription coverage

This makes it easy to tailor a policy based on the client’s preferences and risk tolerance.

Cross-Selling Opportunity

Short-Term Care pairs well with:

• Medicare Supplement or Advantage plans
• Hospital indemnity insurance
• Final expense life insurance

It’s a natural upsell when you’re already having conversations around aging, recovery, or end-of-life planning. Many clients don’t even know this type of coverage exists until you bring it up.

Watch a quick YouTube video on why and how to sell ancillary with Medicare

Boost Your Business

Offering STC can:

• Differentiate you from other agents
• Add value to every client conversation
• Increase your commission opportunities with a product that’s often overlooked

It shows clients that you’re thinking beyond just the basics and that you truly care about protecting their finances.

Click here to get an idea of the different types of ancillary products available to your clients.

Short-Term Care insurance isn’t a replacement for long-term care; but for many clients, it’s a value-based solution. As an agent, it’s a chance to educate, protect, and build lasting client relationships.

So if STC isn’t in your toolkit yet, it’s time to take a closer look. Your clients (and your bottom line) will thank you.

Are you ready to add ancillary roducts to your business; click here for contracting

We will use this post to discuss why use local Medicare agents as opposed to call center agents. When it comes to Medicare, one size doesn’t fit all. Choosing the right plan means considering health needs, prescriptions, doctors and even budget. So when trying to sort through all the options, who provides the advice can make all the difference.

Here are some reasons that using a local Medicare agent might be a smarter move than a call center representative:

Personalized, Face-to-Face Service

Local agents often offer in-person consultations, so beneficiaries are not just a number on a screen agents actually get to know their clients. This allows agents to better understand client’s healthcare needs and walk them through their options in a clear, personal way. For beneficiaries who prefer a handshake over hold music, a local agent wins every time.

Ongoing Support

Call center agents are usually focused on getting prospects enrolled, then moving on to the next call. Local agents, on the other hand, build relationships. They often provide support throughout the year. They can provide help with billing issues, coverage questions, or preparing for the next Annual Enrollment Period. Local agents can be a trusted advisor, not just a voice on the phone.

More Than Just Enrollment Help

Local agents can assist with:

• Plan comparisons
• Prescription drug coverage analysis
• Medicare Savings Programs
• Low Income Subsidy (Extra Help) applications
• Coverage questions that come up
• Annual plan reviews

They often go the extra mile to make sure clients understand their options; not just during enrollment, but year-round.

Independent Unbiased Advice

Many local Medicare agents are independent brokers who can compare plans from multiple insurers. That means they’re not tied to one company or incentivized to push a single product. Call center agents, by contrast, often work for a single insurer or are bound by contracts that limit what they can offer. Call center agents often work on meeting a quota for the carriers and do not have the ability to ensure prospects receive the best available, personal coverage.

Local agents also have quoting and enrollment tools to provide plan comparisons clietns can see plans side by side. This makes choosing the right coverage easy.

Watch a YouTube video on Sunfire BlazeSync customer intake form

Learn about the changes to Connecture and Sunfire for 2025

Understanding of Local Networks

Local agents know which doctors, hospitals, and pharmacies are in-network in the prospect’s local area. They’re familiar with regional plan availability, local provider preferences, and even which plans tend to have the fewest issues. That kind of insight is hard to get from a national call center.

No Cost – It’s Free

Here’s the kicker: local Medicare agents are typically free to use. They’re paid by the insurance companies (not out of the client’s pocket), and the price of a plan is the same whether enrolllees go through an agent or enroll themselves.

Agents; learn the value of maintaining your Medicare book

Medicare coverage is too important to leave to a rushed phone call with someone who may never talk to the beneficiary again. Local agents offer real relationships, local knowledge, and ongoing support that can help clients feel more confident about their healthcare coverage choices. This is a relationship that is on going not just for one day.

Agents; click here for a SCOPE

In this post, we discuss the basics of Medicare enrollment for those approaching 65 and for agents getting started in Medicare sales. Trying to navigate all the ins and outs of Medicare may be a bit confusing, but it does not have to be. Understanding when and how to enroll in Medicare is key to ensuring beneficiaries receive the best coverage for their needs.

Original Medicare

Original Medicare consists of Part A & Part B. It is a federal health insurance program put in place for individuals aged 65 and older or younger individuals with a qualifying disability or those with End-Stage Renal Disease (ESRD). Medicare provides coverage for many healthcare services, including hospital stays (Part A), and doctor visits (Part B).

It is important to note; Medicare covers approved expenses at about 80% after beneficiaries meet the Part B deductible.

The Parts of Medicare

Before diving into enrollment, it’s helpful to understand the different parts of Medicare:

• Part A (Hospital Insurance): Covers inpatient hospital stays, skilled nursing facility care, hospice, and some home health care.
• Part B (Medical Insurance): Covers outpatient care, doctor visits, preventive services, and some home health care services.
• Part C (Medicare Advantage): An alternative to Original Medicare (Parts A and B) offered by private insurers. Often includes additional benefits like vision, dental, and prescription drug coverage.
• Part D (Prescription Drug Coverage): Helps cover the cost of prescription medications. Beneficiaries may receive coverage through a Medicare Advantage plan or a stand-alone PDP plan.

Medicare Enrollment Periods

There are several enrollment periods to be aware of:

Initial Enrollment Period (IEP)

This is the first opportunity to sign up for Medicare. It lasts seven months:

• Begins three months before the month individuals turn 65
• Includes their birth month
• Ends three months after the month they turn 65

In most cases, those already receiving Social Security benefits are auto-enrolled in Original Medicare (Parts A and B). If they are not, they must enroll via the Social Security Administration.

General Enrollment Period (GEP)

Individuals who miss their Initial Enrollment Period can use the GEP to enroll between January 1 and March 31 each year. Coverage starts the first day of the month following enrollment. Please note; those who miss their initial enrollment period and don’t have other creditable coverage (usually through an employer) may face late enrollment pentalties.

Special Enrollment Period (SEP)

In some cases, individuals qualify for a Special Enrollment Period if they delayed Medicare because they had coverage through an employer or union. This SEP allows them to enroll without penalty when their other coverage ends.

Annual Enrollment Period (AEP)

AEP Each year from October 15 to December 7, beneficiaries can:

• Switch between Original Medicare and Medicare Advantage
• Switch from a Medicare Advantage plan back to Origianl Medicar
• Change from one Medicare Advnatage plan to another
• Join, switch, or drop a Part D plan

Medicare agents watch a YouTube video on marketing rules for AEP

How to Enroll in Medicare

There are a few ways to enroll in Medicare:

• Online at ssa.gov/medicare
• By phone by calling Social Security at 1-800-772-1213
• In person at your local Social Security office (call ahead for an appointment)

A Few Tips

• Beneficiaries should mark their calendar so they do not miss their enrollment window. Delaying enrollment can lead to gaps in coverage and penalties.
• Ask questions! Medicare can be complex, and there are plenty of free resources available to help. This is where it is important to have a reputable , licensed Medicare agent to provide guidance.
• Because Medicare does ot cover 100% of medical expenses, beneficiaries need to consider additional coverage options; Medicare Advantage or Medicare Supplement and Prescrption Drug plans.

Learn how to appeal a Medicare LEP

Understanding the basics of Medicare enrollment is a vital first step in managing healthcare needs. With a little preparation and the right information, beneficiaries can make good decisions that provide peace of mind and the coverage that best suits their needs.

Agents:

If you need a scope of appointment – click here

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Because there are so many regulations for Medicare sales, agents need to constantly be learning. That is why we will discuss Medigap Guaranteed Issue Rights in this post. This is a subject that is crucial to understand but often misunderstood.

Medigap Guaranteed Issue Rights

Guaranteed Issue (GI) Rights are protections under federal law that provide beneficiaries the right to purchase certain Medigap (Medicare Supplement) policies without having to go through medical underwriting. That means insurance companies can’t:

• Deny the beneficiary enrollment in a policy
• Charge enrollees more based on health
• Impose waiting periods for pre-existing conditions (in most cases)

These rights kick in during specific situations, often tied to changes in your health coverage or life circumstances.

When Guaranteed Issue Rights Apply

Here are some common scenarios that trigger GI rights:

Turning 65

Anyone who turns 65 has a 6 month period where they can enroll in a Medigap plan without having to go through underwriting.

Loss of Employer or Union Coverage

Individuals that have health coverage through an employer or union (including COBRA) that ends have 63 days from the end of that coverage to buy a Medigap policy using GI rights.

Medicare Advantage Plan Leaves a service Area

If a Medicare Advantage (MA) plan no longer provides service the enrollee’s area, is terminated, or they move out of the plan’s service area, they can return to Original Medicare and buy a Medigap policy under GI protections.

Beneficiary Tries a Medicare Advantage Plan for the First Time

Those who joined an MA plan when they were first eligible for Medicare at 65 and switch back to Original Medicare within the first 12 months can buy any Medigap policy offered in their state.

Medigap Insurance Company Goes Bankrupt or Misleads You

If the Medigap insurer goes out of business or the beneficiary is misled into buying a policy, they have GI rights to purchase another policy.

Trial Rights

In some cases, beneficiaries have “trial rights” that allow them to try out an MA plan and return to a Medigap plan under GI protections. This typically applies if they dropped a Medigap policy for an MA plan and want to switch back within 12 months.

Rules and Timelines

• Typically individuals have a 63-day window from the date previous coverage ends to use their GI rights.
• The plans that are guaranteed issue depend on eligibility and location. The standard Medigap plans are Plans A, B, C, F, K, or L.
• The federal government mandates guaranteed issue rights, although some states offer broader protections. It is important to check the rules for each state.

Watch a YouTube video on Medicare Supplement Underwriting GI & non-GI states

Why Guaranteed Issue Rights Matter

Without GI rights, applying for Medigap outside the initial enrollment period often means going through medical underwriting. Those who have pre-existing conditions could be denied coverage or charged more.

GI rights are a safeguard. They ensure that when life throws a curveball like; losing coverage, moving, or simply changing your mind, beneficiaries can access supplemental coverage without penalty.

Birthday Rule

There are 6 states that allow beneficiaries to change Medigap plans without underwriting during a specific period before/after their birthday each year on a GI basis. The states that have this rule are: CA, ID, IL,KY, LA, MD, NV, OK & OR. Each of these states has it’s own specific rules for this.

Important:

Some states allow beneficiaries to change Medigap plans any time or at specific times without undergoing medical underwriting. These states are: CT, NY, MA & ME.

In CT & NY enrollees change Medigap plans anytime of the year without underwriting. Massachusetts offers an annual open enrollment where beneficiaries do not have to go through underwriting. In Maine there is an open enrollment in June where Medicare Supplement enrollees can switch to a similar or lower benefit plan without underwriting.

Anyone applying under GI rights; insurance companies may request documentation (like letters from the former insurer). Keeping all notices and paperwork handy makes the application process smoother.

Medigap Guaranteed Issue Rights are an important part of the Medicare landscape, especially for those navigating transitions. Understanding when and how they apply allows you to help clients make informed choices and avoid gaps in healthcare coverage.

Understanding Medicare Advantage enrollment periods; when to join, switch or leave a plan is crucial to receive necessary healthcare coverage. Although even if you know which plan you want, when you can enroll in a Medicare Advantage plan isn’t always straightforward.

In this post, we break down the Medicare Advantage enrollment periods so beneficiaries do not miss an opportunity to get teh coverage they need.

Medicare Advantage

Medicare Advantage, also known as Medicare Part C, is an alternative to Original Medicare. In other words, these plans provide coverage for Part A (hosptial) & Part B (medical) expenses. They are offered by private insurance companies that are approved by Medicare. The plans often include extra benefits like vision, dental, hearing, and Part D (prescription drug coverage).

However, individuals can’t just sign up any time they want to. There are specific rules that specific govern when individuals can join or make changes.

Initial Enrollment Period (IEP)

This enrollment period is for those who are either turning 65 or newly eligible for Medicare.

The Initial Enrollment Period is a 7-month window:

• Starts 3 months before the month individuals turn 65
• Includes the birthday month
• Ends 3 months after the birthday month

During this time, individuals can enroll in Original Medicare (Parts A and/or B). They can also choose to enroll in either a Medicare Advantage plan with or without Part D or a Medicare Supplement and a stand-alone Part D plan.

Annual Enrollment Period (AEP)

Medicare’s AEP runs from October 15 through December 7 each year. This enroll,ment period is a time whe anyone enrolled in a Medicare plan should meet with theor Medicare agent and go over their options for the coming year.

During this time, beneficiaries can:

• Switch from Original Medicare to a Medicare Advantage plan
• Switch from one Medicare Advantage plan to another
• Drop a Medicare Advantage plan and return to Original Medicare
• Join, drop, or switch a Part D prescription drug plan

Changes made during AEP take effect January 1 of the following year.

Medicare Advantage Open Enrollment Period (MA OEP)

Each year the MA OEP runs from January 1 through March 31. This enrollment period is available to those already enrolled in a Medicare Advantage plan

During this time, beneficiaries can:

• Switch to a different Medicare Advantage plan
• Drop Medicare Advantage and return to Original Medicare (and optionally join a Part D plan)

Please Note: Medicare beneficiaries cannot join a Medicare Advantage plan for the first time during MA OEP.

Watch a quick YouTube video on Medicare OEP best practices.

Special Enrollment Periods (SEPs)

Medicare SEP are available to beneficiaries who experience specific life events.

Individuals may qualify for an SEP ( Special Enrollment Period) if they:

• Move out of their plan’s service area
• Lose other health coverage (like employer sponsored insurance)
• Qualify for Extra Help or Medicaid
• Live in or move into a nursing home
• Miss a valid election period due to a FEMA declared emergency
• Experience plan contract changes (e.g., plan termination)

The time allowed to use an SEP varies. Therefore, it is important for eligible beneficiaries to act promptly so they don’t miss the enrollment opportunity.

5-Star Special Enrollment Period

If a Medicare Advantage plan earns a 5-star rating from CMS, beneficiaries can switch from their current plan to the 5 star plan from December 8 – November 30 of the following year. Plan enrollees can use this election period only once per calendar year.

This allows plan enrollees to move to a top-rated plan outside of the usual enrollment windows.

When it comes to Medicare Advantage enrollment, timing is important. Missing an enrollment window can mean waiting months for another opprotunity to change coverage. This can leave beneficiaries in a plan that no longer fits their coverage needs.

Each year, Medicare eligible indivduals wonder which type Mediare plan will cover their helath care needs best. Many beneficiareis wonder if they should enroll in a Medicare Supplement or a Medicare Advantage plan. Although both options provide comprehensive coverage, it is important for individuals to consider their needs and budget to make the best choice. In this post, we will go over some ways to decide the best candidates for MAPD Plans.

People Who Want All-in-One Coverage

MAPD plans are good for; anyone who prefers having all their healthcare benefits managed under a single plan. Plan enrollees only need to carry one ID card and pay for Part B and 1 plan premium. Although, some plans do not even charge a premium.

Private insurers offer Medicare Advantage plans (Part C) and bundle together:

• Part A (hospital coverage)
• Part B (medical insurance)
• Often Part D (prescription drug coverage)
• Plus extra perks like vision, dental, hearing, and wellness benefits

Budget-Conscious Individuals

Many MA plans offer low or even $0 monthly premiums. This is in contrast to Medigap plans (used with Original Medicare), which usually have higher premiums.

While enrollees are still responsible for copays and out-of-pocket costs, Medicare Advantage plans have annual out-of-pocket maximums. The maximums provide financial protection Original Medicare alone doesn’t offer. In other words, these plans are a great choice for those on a fixed income trying to cap their annual healthcare costs.

People Who Don’t Travel Often

Because Medicare Advantage plans generally have local provider networks, enrollees must see doctors and hospitals within the plan’s service area for non-emergency care.

These plans are a good choice for individuals who don’t travel often and usually receive care in their local area. MAPDs might not be a good fit for those who live in multiple states throughout the year.

Those Who Value Extra Benefits

Because Medicare Advantage plans usually offer additional benefits beyond what Original Medicare provides, some people prefer them over other options.

Some of the additional benefits (not included in Original Medicare) plans may offer are:

• Dental exams
• Vision exams and an eye wear allowance
• Hearing exams and hearing aid coverage
• Gym memberships
• Transportation to medical appointments
• OTC items
• Healthy food cards

Please note; this list varies by carrier plan type and area. Not all benefits are included in every plan.

Comfortable with Managed Care

Many Medicare Advantage plans involve managed care structures, like HMOs or PPOs, that coordinate your services and may require referrals or prior authorizations.

People who are comfortable navigating provider networks, or calling their plan for care coordination support may find these plans are a good option.

Those in Good Health

Because MA plans often come with copays for services, they may be more cost-effective for individuals who don’t expect to need frequent medical treatment. In other words, Medicare Advantage plans may be a good fit for healthy retirees who normally see a doctor a few times a year for annual checkups or minor services.

Best Candidates for MAPD Plans

Choosing the right Medicare plan depends on personal health needs, budget, and lifestyle. A Medicare Advantage plan can offer convenience, cost savings, and extra benefits,, only if it aligns with how much and where helathcare is needed.

Before enrolling, consider:

• Current doctors (are they in the plan’s network?)
• Medications (are they covered?)
• How often you travel
• Comfort level with managed care.

Medicare Advantage plans are not one-size-fits-all, but for the right person, they can be a useful, value-packed healthcare solution.

Agents click here to learn how Connecture and Sunfire can make quoting and enrollment easier

Before switching or enrolling for the first time, be sure to review options carefully. It is important to check each year during Medicare’s Annual Enrollment Period (AEP) for the plan that best suits current health care needs and budget. A licensed Medicare agent can provide options and help find the most suitable coverage option.