April 2025

Understanding The Basics of Medicaid

By Ed Crowe | General Articles | 0 comment | 3 April, 2025 | 0

Medicaid is a crucial government program providing healthcare coverage to millions of low-income individuals and families. Although it is so important, many people do not understand how it works, who qualifies, and what services it provides. This post will help with understanding the basics of Medicaid so individuals can better navigate the program.

What is Medicaid

Medicaid is a joint federal and state program designed to offer healthcare coverage to eligible low-income individuals, including children, pregnant women, elderly adults, and people with disabilities. Unlike Medicare, which is primarily for disabled individuals and those 65 and older, Medicaid eligibility is based on income and other factors.

Each state administers it’s own Medicaid program. The states must follow federal guidelines but have flexibility to expand coverage and determine eligibility criteria. In other words, Medicaid programs vary significantly from one state to another.

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Who Qualifies for Medicaid

In general, Medicaid eligibility is based on income and size of household. Although, factors such as disability, age, and pregnancy are also condsidered when determining qualification. In states that have expanded Medicaid under the ACA (Affordable Care Act), individuals with incomes up to 138% of the federal poverty level (FPL) qualify for Medicaid coverage.

In general, Medicaid provides coverage for individuals who have income levels that meet state qualifications. Those who may qualify are:

Individuals, families, children and elderly individuals with limited income
Pregnant women
Individuals with disabilities

Each state has an online portal or office where individuals can apply for Medicaid benefits. Usually they can go to their state’s health department or the federal Healthcare.gov website.

What Medicaid Covers

Medicaid provides comprehensive healthcare services that include the following:

Hospital and emergency care
Doctor visits and preventive care
Maternity and newborn care
Prescription medications
Mental health and substance abuse treatment
Long-term care services (this includes; nursing home care and home health services)
Dental and vision care (coverage varies by state).

Although federal guidelines require the states to provide coverage for essential services, each state has the ability to cover additional services.

How to Apply for Medicaid

Each state has it’s own process to apply for Medicaid coverage. In general, it is pretty straight forward. We have listed some of the common steps for the application below:

Check Eligibility: Use the state’s Medicaid website or the federal Healthcare.gov website to verify qualification.

Gather Necessary Documents: Applicants will need proof of income, identification, Social Security numbers, and information about household members.

Submit an Application: There may be several ways to submit an application; online, in person, by mail, or over the phone. This depends on the state the enrollee is in.

Wait for Approval: Processing times vary, but applicants will receive notification about their status and coverage details.

Medicaid and Other Health Programs

Many Medicaid beneficiaries qualify for additional assistance programs, such as the Children’s Health Insurance Program (CHIP), which provides coverage for children in families with incomes too high for Medicaid but too low for private insurance. Many states also offer food and housing and utilities assistance programs.

There are also specific Medicare programs that provide Extra Help to beneficiaires.

Learn the difference bewtween Medicare and Medicaid

For those who qualify for both Medicare and Medicaid (dual-eligible individuals), Medicaid helps cover Medicare premiums, copays, and additional services that Medicare doesn’t fully cover, such as long-term care.

Medicaid plays an important role in ensuring access to healthcare for millions of Americans. Understanding the eligibility requirements, coverage options, and application process help individuals and families access the benefits available to them. Because Medicaid rules and benefits vary by state, it’s essential to check the local Medicaid office for accurate and up-to-date information.

Medicare Agency Contracting Levels

By Ed Crowe | General Articles | 0 comment | 2 April, 2025 | 0

Understanding Medicare agency contracting levels can help agents who may want to expand thier business set clear goals for themselves. The contracting process determines the level of authority, commissions, and support that an agency or agent receives when selling Medicare Advantage (Part C), Medicare Supplement (Medigap), and Medicare Part D prescription drug plans. This blog provides some general information about the different levels of Medicare contracts.

Please keep in mind, each carrier has different requirements for contract levels. They may also have different names for contract levels than what we have listed here.

Levels of Medicare Contracting

Medicare sales agencies typically operate under a hierarchical contracting structure. Each level comes with varying degrees of responsibility and commission structure.

Most carriers will pay street level commissions directly to the downline/sub agent with the override paid to the agency. Overrides range from $50.00 to $150 per sale. This varies by company and agency level. Many agents know what the annual street level compensation is and will not work with an agency if they will be taking any part of the street compensation.

Agents

At the entry level, individual agents contract directly with an Medicare agency and in some cases, with the insurance carrier. There are two main types of agent contracts:

Captive Agents: Work exclusively for one carrier and can only sell that carrier’s Medicare products.
Independent Agents: Have the flexibility to contract with multiple carriers, allowing them to offer a variety of Medicare plans to clients.

Individual agents can either receive street commissions or be LOA to the agency they work under.

General Agencies (GAs)

General Agencies (GAs) operate as intermediaries between independent agents and higher-level marketing organizations, such as FMOs and NMOs. GAs typically provide agents with carrier access, sales support, and some marketing resources, they may not offer the same level of training and tools an FMO can provide. The GAs recieve an override commission for business their downline agents write.

Managing General Agencies (MGAs)

MGAs function at a higher level than GAs, to be an MGA, you must have a greater number of downline agents than a GA. They may provide additional administrative support and agent oversight. structures. MGAs may have direct contracts with carriers, allowing them to receive greater overrides on downline agent sales than a GA level contract. This may provide them financing to offer agents advanced sales tools and training.

Senior General Agencies (SGAs)

SGAs operate at an even higher level than MGAs, typically overseeing some MGAs and GAs. They have strong carrier relationships, access to exclusive products, and higher commission opportunities. SGAs should provide large-scale support, including compliance oversight, marketing assistance, and leadership training for agencies beneath them.

Field Marketing Organizations (FMOs)

FMOs serve as intermediaries between carriers and independent agents or smaller agencies. They provide training, marketing resources, compliance support, and higher commission opportunities. FMOs typically contract with multiple carriers and offer agents the ability to represent various Medicare plans.

Take a look at the programs Crowe offers agents & agencies

National Marketing Organizations (NMOs)

NMOs operate at a level above FMOs and work with a broad network of agents, agencies, and FMOs. These organizations have high-level contracts with carriers, allowing them to negotiate competitive commission structures and access exclusive sales resources. NMOs focus on large-scale distribution and typically offer robust technology and compliance support.

Insurance Carriers

At the top level of the hierarchy, insurance carriers (such as UnitedHealthcare, Humana, and Aetna) contract directly with NMOs, FMOs, and, in some cases, GA levels or individual agents. Carriers set the terms of contracts, commission structures, and compliance guidelines that all agents and agencies must follow when selling Medicare plans.

Keep in mind; all agents and agencies must also folow CMS guidelines.

Contracting Considerations

Commission Structure: Higher-level contracts often provide better commission overridess, but require meeting performance thresholds and a specific number of downline/sub agents.

Training and Support: FMOs and NMOs often provide valuable training, lead generation, and compliance assistance.

Carrier Relationships: Access to multiple carriers gives agents flexibility to offer the best plan options for clients.

Compliance Requirements: Medicare sales are highly regulated, and agencies must ensure they follow CMS (Centers for Medicare & Medicaid Services) guidelines.

Ready to join the team at Crowe – click here for contracting

Understanding Medicare sales agency contracting levels is crucial for agents and agencies looking to optimize their business. Whether operating as an independent agent, partnering with a GA, MGA, or working under an SGA, FMO, or NMO, choosing the right contracting level can significantly impact commissions, resources, and overall success in the Medicare market. Agents should carefully evaluate their options to align with an organization that best supports their business goals.

HSAs and Medicare Enrollment

By Ed Crowe | General Articles | 0 comment | 1 April, 2025 | 0

Health Savings Accounts (HSAs) offer a tax-advantaged way to save for medical expenses, but their benefits and rules change once you enroll in Medicare. Understanding HSAs and Medicare enrollment is crucial to avoid tax penalties and continue to benefit from the HSA.

How HSAs Work Before Medicare

An HSA is a tax-advantaged account that allows individuals with a high-deductible health plan (HDHP) to save and pay for qualified medical expenses. Contributions to HSAs are tax-free, in other words, any contributions lower taxable income. All investment growth and earnings are tax-free; indivduals can invest HSA money and will not pay taxes on any gains as long as the money is in the account. Additionally, money withdrawn for qualified medical expenses is tax-free. However, once an individual enrolls in Medicare, they can no longer contribute to an HSA.

Medicare Enrollment and HSA Contributions

Once enrolled in Medicare, the ability to contribute to an HSA stops. This includes enrollment in any part of Medicare, either Part A (hospital insurance) or Part B (medical insurance). Those who continue making HSA contributions after Medicare enrollment face tax penalties.

A few things to consider:

Medicare Enrollment Date Matters: HSA contributions must stop the month your Medicare coverage begins. If you enroll in Medicare mid-year, your contribution limit for that year will be prorated based on the number of months you were eligible to contribute before Medicare enrollment.

Retroactive Medicare Coverage: For those who enroll in Medicare after turning 65, Part A coverage may be retroactive for up to six months (but no earlier than the month you turned 65). This retroactivity can impact HSA contributions. Beneficiaries should stop contributing at least six months before applying for Medicare to avoid penalties.

Employer Considerations: Anyone working past 65 with employer-sponsored health insurance with an HSA option, may want to delay Medicare enrollment and continue contributing. However, once enrolled in Medicare, even retroactively, HSA contributions must stop.

Using HSAs After Medicare Enrollment

Although individuals can’t contribute to an HSA after enrolling in Medicare, they can still use the funds in their account. Benficiaries can use HSA funds tax-free for qualified medical expenses, including:

Medicare premiums (except for Medicare supplement policies)
Out-of-pocket medical costs such as copays, deductibles, and prescription drugs
Long-term care services
Some over-the-counter medications and medical supplies

Important: after age 65, HSA withdrawals for non-medical expenses are not subject to the 20% penalty that applies to those under 65. Although, those withdrawals are taxed as income.

Transition from HSA to Medicare

To avoid tax issues and optimize benefits, consider the following:

Time Your Medicare Enrollment: Those who plan to work past 65 and want to continue HSA contributions, consider delaying Medicare enrollment if employer coverage allows it.

Stop Contributions in Advance: Individuals planning to enroll in Medicare, stop HSA contributions at least six months before applying to avoid penalties due to retroactive Medicare coverage.

Maximize Existing HSA Funds: Plan the use of HSA funds for healthcare expenses, including Medicare premiums and out-of-pocket costs.

HSAs provide valuable benefits, but their rules change upon Medicare enrollment. Proper planning helps maximize savings and avoid unexpected tax penalties. Individuals approaching Medicare eligibility should consider consulting a financial or tax advisor to help ensure a smooth transition.