Blog

In some cases, Medicare beneficiaries miss an enrollment period due to a FEMA emergency. When this happens, beneficiaries may be eligible for a DST SEP. It is imperative that agents are aware of the New Medicare FEMA SEP rules to assist clients. The DST SEP is available to qualified individuals who miss an opportunity to enroll in a Medicare plan.

Medicare FEMA SEP  

The DST SEP is an enrollment opportunity CMS offers to Medicare beneficiaries affected by either weather-related emergencies or major disasters. The FEMA SEP lets those who miss a valid election period to either enroll in or disenroll from a Medicare plan. The enrollment takes effect the first day of the month after application is submitted.

This is only available in areas where FEMA, state or other local government officials declare an emergency or disaster. FEMA emergencies start when the incident occurs and lasts for two months up to one year after the start or the extension period begins.   

Important changes the the FEMA SEP

On December 3, 2024, CMS released a memo that announced changes to the DST election. These changes go into effect as of April 1, 2025.

If a beneficiary needs to submit an application using the DST election period either on or after April 1, 2025, the application must be submitted directly through CMS. Beneficiaries can call 1-800-MEDICARE or TTY 1-877-486-2048 to submit an application.

In other words, CMS will not accept applications that use the DST election even if they are broker assisted.

Any enrollment application that uses this election will be labeled as using an invalid election period. The plan will then attempt to contact the enrollee and obtain a valid election period. If the plan cannot verify a valid election period, the application will be denied.

Important: missing or invalid elections do not trigger the (RFI) Request for Information process. Therefore, beneficiaries do not have additional time to respond to the inquiry or correct their election.

Please note; applications and disenrollment forms will be updated to remove the DST election.

Reasons to use this SEP

There are varied opportunities to use the SEP. This ensures individuals have the coverage they need.

If the beneficiary resides where a natural disaster (earthquake, flood, wildfire, hurricane, tornado or other specific incident) resulting in a missed valid enrollment period. Sometimes disasters cause beneficiaries to have to leave their home. This may result in them missing their enrollment period and enable the use the FEMA SEP.

The SEP is sometimes available when a beneficiary relies on a family member or other caregiver who is impacted by a disaster and they are unable to assist them during their enrollment period. 

Other instances that allow for SEP use include; inability to access Medicare plan information or submit a timely enrollment due to a FEMA declared disaster. Enrollees may also use the SEP when the beneficiary’s healthcare provider of facilities are impacted by the disaster. This can result in the inability to receive necessary information to make an informed decision.

Rules for Eligibility for Medicare Disaster SEP  

In order to use the SEP, the beneficiary must live in the are where the disaster occurred. They must have missed a valid enrollment period (AEP, IEP, OEP) during the time of the incident as long as they did not already make a change during the enrollment period. It is also acceptable for those who need assistance from another person to complete the enrollment or make healthcare decisions.

Who cannot use this SEP

Anyone who has already changed their plan during a valid election period can’t use the FEMA election to change it again. Beneficiaries must call 1-800-MEDICARE or TTY 1-877-486-2048 to submit an application in a timely manner to avoid missing their window to enroll. 

CMS will begin their Medicare drug price negotiations 2026 with 10 popular high cost prescription medications. CMS has announced the first 10 drugs that will be subject to price negotiations.  The negotiations are part of the Inflation Reduction Act.  Until recently, Medicare was able to negotiate prices for the medical care beneficiaries receive; this did not include the costs of medications.

If the current plan does not change;  on January 1, 2026, the negotiated drug prices for the first 10 drugs will go into effect.

Watch a YouTube video on how to handle non-commissionable PDP plans 

Medicare is set to negotiate the cost for some of the more expensive prescription medications with the drug manufacturers.

It is important to note; the negotiations do not apply to drugs that offer a generic equivalent.

The first 10 medications CMS will negotiate are:

1. Eliquis (a blood thinner)
2. Enbrel (for rheumatoid arthritis)
3. Entresto (for heart failure)
4. Farxiga (for diabetes, heart failure & chronic kidney disease)
5. Fiasp & Novalog (for diabetes)
6. Imbruvica (for blood cancers)
7. Januvia (for diabetes)
8. Jardiance (for diabetes)
9. Stelara (for psoriasis & Chron’s disease)
10. Xarelto (a blood thinner)

The 10 drugs listed above were chosen because they made up almost 20% of the Medicare Part D spending from June 2022 through the end of May 2023.  Medicare Part D covers prescriptions beneficiaries take at home.  Part D does not cover medications medical providers administer in medical facilities. When this is the case, Medicare Part B covers the drugs.

Just the start

The first 10 drugs are just the start of the proposed price negotiations.  In 2027, the plan is to add 15 more and the hope is to add more in the years to follow.  This plan could change if the drug manufacturers can successfully stop the price negotiations.

Learn about the Medicare prescription payment program.

Drug manufacturers

As it stands, if the drug companies do not agree to the negotiations, they face possible tax penalties.  Although drug manufacturers can avoid the tax penalty if they remove their drug from the Medicare market.  Unfortunately, if they do that, they take away lifesaving drugs from Medicare beneficiaries and lose a large part of their market share.

Some large drug companies have hired legal counsel to stop the price negotiations.  They argue the loss in income will affect their ability to fund important research and development and that in turn, hinders their ability to produce new medicines.

The Negotiation Process

1. Drug Selection: Medicare will identify eligible drugs based on spending and clinical impact.
2. Price Negotiations: CMS will negotiate directly with manufacturers to establish a “maximum fair price.”
3. Implementation: The agreed-upon prices for drugs covered under Medicare Part D will take effect in 2026 with additional drugs phased in over the following years.

Potential benefits

Lower out-of-pocket costs: Beneficiaries could noticeable reductions in their high cost medication expenses.

Federal savings: By reducing the prices for some of the most expensive drugs, the policy could generate substantial savings for Medicare, potentially freeing up funds for other healthcare initiatives.

Health care equity: Lower drug costs may improve access to essential medications for underserved populations.

Concerns

While the policy is praised by some, it is not without controversy.

Impact on innovation: Pharmaceutical companies warn that reduced revenues could lead to decreased availability of funds for research and development. This could potentially slow the pace of medical innovation.

Legal and logistical hurdles: Industry groups have initiated legal challenges, questioning the constitutionality of the negotiation framework. Additionally, the administrative complexities of implementing the program are significant.

Click here to find out about the $2,000 drug cap for 2025

Looking Ahead

As the potential implementation approaches, many groups are watching closely to see what the impact of this policy will be. While challenges remain, the policy’s success could pave the way for broader reforms that could have an effect on the entire healthcare system.

Monitoring both long term and short term effects of this program are essential to determine if Medicare’s negotiating power achieves its intended goals or brings unintended consequences.

If you are looking for an FMO, find out what we have to offer!

Are ready to join our team, click here for online contracting.

Because navigating Medicare enrollment period options can feel overwhelming, we will explain one specific enrollment opportunity. For beneficiaries seeking flexibility in healthcare coverage, Medicare supplements provide a good option. Because of this, the Medicare Supplement birthday rule is an important policy to understand. This rule, available in certain states, offers a window of opportunity to change Medicare Supplement (Medigap) plans without medical underwriting.

What Is the Medicare Supplement Birthday Rule

The Medicare Supplement birthday rule allows beneficiaries to switch Medigap plans annually around their birthday without undergoing medical underwriting. This means insurers cannot deny coverage or charge higher premiums based on health status during the designated timeframe.

Medicare supplement plans help cover out-of-pocket costs not paid by Original Medicare, such as copays, coinsurance, and deductibles. However, outside of the initial enrollment period, switching plans typically requires medical underwriting, which can be a barrier for those with pre-existing conditions. The birthday rule removes this obstacle during its specific enrollment window.

States That Have the Birthday Rule

As of now, the Medicare Supplement birthday rule is not a federal policy; it is enacted at the state level. Currently, 8 states including California, Idaho, Illinois, Kentucky, Louisiana, Maryland, Nevada and Oregon have implemented variations of this rule. Each state’s version differs slightly in terms of timing and eligible plans:

California

Beneficiaries have 60 days from the first day of their birth month to switch Medicare supplement plans to enroll in one with the same or a less benefits. They also have the option to switch insurance carriers during this period.

Idaho

Those who reside in ID have 63 days from their birthday to switch Medicare supplement plans with the either the same or less benefits. They can also switch to another insurance carrier if they like.

Illinois

Beneficiaries in IL have 45 days from their birthday to change Medicare supplement plans with either the same or less benefits. This rule only applies to plans with the existing insurance carrier or an affiliate of the current carrier. The affiliate carrier was added in 2024. In order to To qualify for the birthday rule in IL, beneficiaries must be between 65 and 75.

Kentucky

As of 1-1-24, KY allows Medicare supplement enrollees to switch to another supplement carrier that offers a plan with the same benefits as their current plan. They must switch within 60 days of their birthday.

Louisiana

In the state of LA, beneficiaries are given 63 days from their birthday to switch to another Medicare supplement plan with equal or lesser benefits. Enrollees are only permitted to enroll in a plan offered by either their current carrier or an affiliate of their current insurer.

Maryland 

As of July 1. 2023, beneficiaries have 30 days from their birthday to change Medicare supplement plans with either equal or less benefits than their current plan.

Nevada

In the sate of NV, the birthday rule allows beneficiaries 60 days form the first day of their birthday month to change supplement plans to one with the same or less benefits. It is also permitted to switch insurance carriers.

Oregon

Beneficiaries have 30 days from the first day of their birth month to switch Medicare supplement plans to another with the same or fewer benefits. They can also change insurance carriers.

Please note; beneficiaries and their agents must verify the state specific rules and timelines.

Watch a quick YouTube video on Medicare enrollment periods

How the Birthday Rule works

Each year plan enrollees should evaluate their current supplement coverage and decide if it still meets their needs. A licensed Medicare agent can help compare available plan options to find one that best suits the needs of the enrollee. They will also be able to advise of the applicable enrollment window using the appropriate birthday rule for each eligible state.

Beneficiaries must submit all applications before the enrollment period ends. Insurers cannot deny applications submitted during the birthday rule period. They are also prohibited from increasing premiums based on health conditions.

Benefits of the Birthday Rule

The birthday rule provides several advantages for beneficiaries. This includes the ability to adjust their coverage to better align with their healthcare needs and budget. It also allows enrollees an opportunity to change plans without fear of rejection.

Considerations for Beneficiaries

Although the birthday rule provides some significant benefits, there are a few important considerations:

State-Specific Rules: The availability and details of the birthday rule depend on where each beneficiary resides. It is not available in every state.

Plan Restrictions: In general, the rule applies only to plans that offer equal or lesser benefits, so beneficiaries cannot use it to upgrade coverage.

Timing: Those who miss the enrollment window must wait until next year’s birthday period to change plans.

Learn about Medigap guarantee issue rules; click here

The Medicare Supplement birthday rule is valuable for eligible beneficiaries. It provides an annual opportunity to change coverage without medical underwriting.

Now that is 2025, both Medicare beneficiaries and agents need to know what the Medicare premiums and deductibles 2025 are so that everyone can plan accordingly. 2025 is the same as previous years; CMS has made changes to both Medicare Part A & Part B premiums and deductibles.

Medicare Part A costs 2025

The majority of beneficiaries do not have to pay a Part A premium if they have worked for at least 40 quarters (10 years) and paid Medicare taxes. Although if they do not qualify for premium free Part A, there are a couple different premium amounts they can pay if they want Part A benefits.

When either the beneficiary or their spouse worked and paid Medicare taxes between 30 and 39 quarters, the monthly premium cost is $285 in 2025. This is an increase of $7 from the 2024 cost of $ 278.

If the beneficiary or their spouse worked at a job and paid Medicare taxes for less than 30 quarters, the premium in 2025 is $518. This an increase of $13 from the cost of $505 in 2024

Part A Deductible and Coinsurance 2025

Part A covers inpatient hospital costs. In 2025, the Part A deductible has gone up $1,676 for each benefit period. This is an increase of $44 from the cost of $1,632 in 2024.

On original Medicare once the beneficiary meets the deductible, the cost for a hospital stay is $0 for days 1-60. The cost for days 61-90 is $419 per day. This is $11 over the cost of $408 in 2024. Once the beneficiary reaches day 91 and over, they start to use their lifetime reserve days and pay $838 per day. that is up from $816 in 2024.

There is no coinsurance charge for days 1-20 in skilled nursing facility stays. The cost for days 21-100 are $209.50 per day in 2025. This is a $5.50 increase from the 2024 cost of $204.

Click here to learn about the Part D drug cap

Part B costs 2025

In contrast to the Part A premium, almost all beneficiaries have to pay a Part B premium. In special circumstances, if a beneficiary qualifies for extra help due to limited income and resources, they may not have to pay the Part B premium.

Part B Premiums & Deductibles

For 2025, the standard monthly premium has gone up $10.30 to $185.00. The premium was $174,70 in 2024.

Learn more about Part B costs

Those with an income level over a specified amount pay an IRMAA. The CMS adds the IRMAA to the standard monthly premium amount. The premium amount each beneficiary pays ranges from $259 to $628.90 per month if the beneficiary pays an IRMAA. The amount is based on their specific income level.

If you have been incorrectly charged an IRMAA, learn how to file an appeal.

The deductible amount for Part B in 2025 is $257, an increase of $17 from the 2024 cost of $240.

It is important for beneficiaries to stay updated on healthcare costs each year to manage their budgets and avoid surprises. CMS makes decisions on Medicare costs based on the projected rise in costs and use of healthcare.

Agents who want to join the team at Crowe, click here for contracting.

There are several ways to get more Medicare referrals. Medicare referrals are a fantastic, no cost way to grow your book of business. Once agents are established as a community resource may rely solely on referrals and do not have to spend money on other lead sources.

Build good relationships with your existing clients

Smart agents make sure they are available to answer any questions or concerns their clients have. This goes a long way to build client relationships. The most important thing you can do as an agent is to listen to your clients to understand their coverage needs and wants. Once they know you have their best interest at heart and provide good service, they are happy to recommend you to their friends and family.

It is important to stay in contact with your clients. This way they remember you are there for them and they do not ask another agent for assistance.

Contacting every client before AEP is another way that helps you stay in contact and also allows you to update their information before it is time to choose a plan for the coming year.

Sunfire and Connecture quoting and enrollment tools 2025 update

When a potential client contacts you be sure to Collect their contact information; email and phone to help you stay in contact if they give you permission to do so. This way agents can send out informational emails or contact a client if needed.  I some instances, agents can use phone numbers to contact clients via text message, if the prospect gives permission and you provide the option to opt out. Texts can be a quick and easy way to provide general information to a large number of clients at once.

Watch a YouTube video on AEP marketing rules

Online presence

A strong online presence is essential in today’s digital age. Agents should create a business profile on social media. Once you create the profile, it is imperative to update the platform with information potential clients may find helpful.  General information on Medicare choices and answers to common questions are good ways to engage readers and encourage repeat visits to your platform. An online presence has the capability of reaching a very large audience and presents you as knowledgeable resource in the field of Medicare.

Let Pinnacle help build your insurance website

Educational workshops

Hosting free Medicare workshops or webinars helps educate the community about coverage options and changes in Medicare. When you provide valuable information to those who need help, you gain credibility as a valuable resource.  Those who attend may refer friends or family to you for guidance when they need help with their Medicare options.

Learn the best practices for educational seminars, click here

Referral Incentives

Be sure to thank those who refer new clients to you with a small gift. Please note; incentives can include a gift card or anything appropriate with a value of not more than $15 that cannot be easily converted into cash. It is extremely important to be complaint when you offer a referral gift. Acknowledging and appreciating referrals encourages your existing clients to actively promote your business.

For referrals that you receive from other agents or professionals (ACA agents, P&C agents, other Medicare agents), referral gifts of up to $100 per sale is allowable. Remember to send the payment so they refer more clients to you.  Please note in most cases, financial planners cannot accept the referral gift.

If you have a client that is happy with the service you provide, you can ask them for referrals if you do it in a way that you are both comfortable with.

Collaborate with Local Businesses

Build relationships with local businesses that serve the senior population. Think about making connections with senior centers, fitness clubs, retirement communities or other local services. These relationships can be mutually beneficial, as you you can refer clients to one another.

Introduce yourself to local healthcare providers, clinics or care facilities. Once they know you and the service you provide, they may form a partnership with you. Having a good rapport with these providers opens doors to a new stream of leads.

Consider volunteering at local healthcare events and workshops to connect with providers and potential clients. Other professionals can refer people who need assistance with Medicare coverage. This also helps establish you as a reliable resource for Medicare coverage needs.

Join an FMO that will help you reach your full potential

For an online contract – click here and be part of the Crowe team

Stay up to date on Medicare plans and regulations

Agents need to stay educated on all available plan options as well as compliance rules. Be sure to attend product training sessions, workshops and conferences.  Broker managers and other agents are both sources of potential referrals if they have a beneficiary who needs assistance in your area.  A well informed and well-known agent is more likely to attract referrals from clients and other professionals.

A large referral network is a great way for MEdicare agents to achieve long-term success. Focusing on client satisfaction and following the suggestions above can help agents build a successful business that brings in new clients and more opportunities.

Many Medicare beneficiaries and agents have heard about the 2025 prescription payment. We will answer the question; what is the prescription payment plan. The plan is available to Medicare Part D beneficiaries. It provides a way to pay high out-of-pocket prescription costs by spreading them out over the course of months instead of all at once at the pharmacy. The prescription payment plan is sometimes called Smoothing. The payment plan is designed to make higher cost prescription drugs more affordable for Medicare beneficiaries.

How the program works

All Medicare Part D plan enrollees who have high cost prescriptions can participate in the prescription payment plan as long as the prescription is on their plan’s formulary. Plan enrollees can have their out of pocket prescription costs divided into manageable monthly payments over the course of the remaining months in the year.

Eligible beneficiaries simply contact their Part D insurance provider to opt into the program. The plan provider calculates the payments evenly over the course of the year. If the plan enrollee wants to add additional prescriptions to the payment plan, they contact their Part D insurance provider to have their payment arrangement adjusted. There is no charge to enroll in this program and beneficiaries do not pay interest or penalties.

Find out more about Part D costs for 2025

How to opt in to the prescription payment plan

It is not complicated to enroll in the plan. In some instances, Part D plan providers will contact beneficiaries who normally take high-cost prescriptions. Interested enrollees should contact the customer service number for their plan provider and request instructions to opt in.

Reasons to use the plan

There are many reasons to enroll in this program. For example; enrollment can provide a way for beneficiaries to manage their budget by spreading out the cost of their medication. This helps them avoid large pharmacy bills.

Knowing there is an alternative to a large bill, may help ensure beneficiaries fill their necessary prescriptions without financial stress. In some cases, beneficiaries may go without needed medications due to budget concerns. This can help eliminate that issue. The plan provides peace of mind with the safety of predictable monthly costs.

Learn about the $2,000 annual cap on Out-of-Pocket prescription costs

Watch a YouTube video on the drug cap for 2025

Because Medicare makes coverage changes each year, both agents and plan enrollees need to stay up to date on all information available. Knowing all the choices available helps beneficiaries receive needed coverage and plan for their year ahead. A licensed insurance agent can provide advice to ensure beneficiaries choose a plan that suite their needs and budget.

If you are a Medicare agent looking for an upline, click here for Crowe online contract