Blog

Are Copays and Coinsurance Different – Copays vs Coinsurance

When you’re reviewing Medicare or health insurance options with a client, one common question that comes up is; are copays and coinsurance different or are they the same. When you’re reviewing Medicare or health insurance options with a client, this can be a common point of confusion. Although both are types of cost-sharing; the portion of healthcare costs the beneficiary pays out of pocket, they work in different ways.

Let’s break it down so you can explain it simply and clearly to your clients.

What is a Copay

A copay is a fixed dollar amount a beneficiary pays for a covered service, no matter the actual cost of the service.

• Example: If a client’s plan lists a $20 copay for a primary care visit, they’ll pay $20 every time they see their doctor for a covered appointment; whether the visit costs $80 or $300.
• Common Copay Examples: Doctor visits, urgent care, prescription drugs.
• Key Point: Copays make healthcare costs predictable.

What is Coinsurance

Coinsurance is a percentage of the total cost of a covered service that the beneficiary pays.

• Example: If a plan has 20% coinsurance for outpatient surgery and the procedure costs $1,000, the client pays $200, and the insurance pays the rest.
• Common Coinsurance Examples: Hospital stays, durable medical equipment, specialist visits under certain plans.
• Key Point: Costs vary based on the service price—no set dollar amount.

How They Work Together

Some services have only a copay, some have only coinsurance, and others might have a combination. For example:

• A specialist visit might have a $40 copay.
• A hospital stay might require 20% coinsurance after the deductible.

Understanding when each applies can help clients better anticipate out-of-pocket costs.

Why It Matters for Medicare Beneficiaries

In Medicare Advantage (Part C) and Medicare Supplement (Medigap) plans, the mix of copays and coinsurance impacts:

• Affordability: Clients with frequent doctor visits may prefer fixed copays.
• Risk: Clients who may face high-cost procedures should understand coinsurance percentages.
• Budgeting: Predictable costs (copays) can make financial planning easier.

Agents see how easy it is to compare MA plans with Sunfire and Connecture

Comparison Table

Click here to learn about agent events and information

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

In other words; copays are a set price you pay every time you visit a specific type of provider. While coinsurance is a percentage of the cost for a provider visit. By making sure your clients understand both, you help them avoid surprise bills and choose a plan that matches their healthcare needs and budget.

Lead Sources for Medicare Agents

For Medicare agents, building a steady stream of quality leads is key to growing your business. Knowing where to find prospects and how to approach them can make all the difference. Below, we explore common lead sources including details on the types of leads that vendors provide, so you can decide what works best for you.

Referrals from Existing Clients

Satisfied clients can be your best source of warm leads. When they recommend you to family or friends, those referrals often come with built-in trust.
Tip: Always politely ask for referrals after helping a client enroll successfully.

Community Events and Educational Seminars

Hosting or participating in local events (grass roots marketing) helps you connect with Medicare-eligible individuals looking for information.
Offer free educational seminars on Medicare basics or plan options to build credibility and become a valued local resource.

Join the team at Crowe – click here for online contracting

Partnerships with Professionals

Collaborate with financial advisors, elder law attorneys, local doctors, pharmacies and other professionals who work with a similar client base.
Note: Provide them with clear information about your services so they can confidently refer clients and vice versa.

Online Marketing

Many seniors and their families research Medicare options online before contacting an agent.
It is a great idea to build a website with educational content, optimize for search engines, and use targeted ads on platforms like Facebook or Google.

Watch a quick YouTube video – How to Manage and Grow a Medicare Book

Purchased Leads and Lead Vendor Options

Lead vendors offer various types of leads to help agents connect with Medicare prospects. Understanding the types can help you choose the best fit for your sales style:

• Live Transfers:
  The vendor screens a prospect live and then immediately transfers the call to you. This means the lead is “hot” and ready to talk, but you must be ready to take the call in real time.
  Best for agents who can handle calls on-demand and want high conversion rates. These are the most costly, but delver the best return on investment.
• Warm Transfers:
  Similar to live transfers, but the prospect has been pre-qualified and warmed up before being transferred. Sometimes these calls are scheduled ahead of time to ensure availability.
  Good for agents who want quality leads but prefer some control over scheduling. These leads usually have a higher price, but the conversion rate is good.
• Direct Leads (Contact Info Only):
  The vendor provides contact details (phone number, email) of prospects who have expressed interest in Medicare plans. You then reach out on your schedule.
  Works well for agents who prefer to set their own pace but requires effective follow-up. Leads of this type are usually less expensive, but have a lower close rate. It’s worth a try if you’re on a budget.
• Internet or Web Leads:
  These leads come from online forms where prospects request information or quotes. These can be fresh but vary in quality. The cost depends on the source and varies.
  Best combined with quick follow-up to maximize conversion.

Note: Choose vendors with verified leads and transparent refund policies. Respond promptly to leads, especially live and warm transfers, since timeliness impacts conversion.

Here are a couple videos from some of our lead vendors:

Learn more about Medicare Express Leads

See what Lead Star has to offer agents

Local Networking Groups

Join your local chamber of commerce or senior-focused groups (senior centers) to build local connections. Be sure you focus on building relationships, not just sales pitches.

Current Book of Business

Cross-selling and annual plan reviews with existing clients can generate repeat business as well as maintaining your book of business. It is a good idea to stay in touch with your current clients through newsletters, birthday cards or check-in calls

Agents; don’t miss important events and information; click here for details.

A diverse lead generation approach works best. Combining referrals, community outreach, online marketing, and vendor leads. Additionally; understanding the nuances of lead types like live and warm transfers gives you flexibility and steadiness throughout the year.

Navigating Medicare Clients with a Power of Attorney

When working as a Medicare agent, you’ll occasionally encounter clients who have a Power of Attorney (POA) in place. This often happens when a beneficiary is unable to make healthcare or financial decisions on their own due to age, illness, injury, or cognitive decline. In this post, we will discuss best practices when writing clients with a POA. Knowing how to handle these situations correctly is critical, not only for compliance, but to protect your client’s best interests and your professional integrity.

Understand the Type of POA in Place

Not all powers of attorney are the same. The POA document may grant authority over:

• Healthcare decisions only – The designated person can make medical choices but may not be authorized to enroll or disenroll the client from Medicare plans.
• Financial matters only – The person can manage finances, including paying premiums, but may not have authority over healthcare decisions.
• Durable Power of Attorney – Remains valid if the client becomes incapacitated and may include healthcare and/or financial authority, depending on the document.

It is important to request and review a copy of the POA before proceeding. Make sure it specifically covers the actions that will take place; choosing coverage, signing enrollment forms or authorizing plan changes.

Verify Legal Authority Before Taking Action

Carriers and CMS have strict rules about working with someone other than the Medicare beneficiary. Each plan carrier may require:

• A copy of the POA on file
• A completed Authorized Representative form
• Verification that the POA is active and valid

Do not rely on verbal claims alone—documentation is key. Acting without proper proof can create compliance issues for you and enrollment problems for your client.

Ready to join the team at Crowe; click here for online contracting.

Communicate Clearly and Respectfully

When a POA is in place, you may need to adjust your communication style:

• Speak directly to the authorized individual about plan options, but keep the beneficiary engaged if they are able to participate.
• Avoid discussing personal health or financial information with anyone not listed on the POA or other authorized documents.
• Be patient; these situations often involve extra steps and emotions.

Document Every Interaction

For your protection and for compliance purposes:

• Keep a record of all communications with both the beneficiary and the POA.
• Note when and how you received POA documentation.
• Record all decisions made and who made them.

Watch a YouTube video on what you need to know before a Medicare sale

Stay Compliant with CMS and Carrier Guidelines

Remember: CMS rules still apply, even if you’re working through a POA. Follow the same protocols for:

• Scope of Appointment (SOA) forms
• Plan comparisons and benefit explanations
• Enrollment timelines and eligibility checks

The Bottom Line

Handling clients with a Power of Attorney requires patience, diligence, and a solid understanding of legal authority. By verifying documentation, following compliance procedures, and maintaining respectful communication, you can protect your client’s interests while safeguarding your own professional standing.

Agents, click here for up-to-date events and information

The Future of Medicare PDPs: Stability and Key Changes

The Medicare Prescription Drug Plan (PDP) market faces a critical year in 2026. How it performs could affect premiums, plan availability, and the long-term viability of traditional Medicare. The future of Medicare PDPs is especially important for some rural beneficiaries who rely more on stand-alone PDPs than Medicare Advantage plans.

Why Stability Matters

Almost half of Medicare beneficiaries use traditional Medicare as opposed to a Medicare Advantage plan. For them, drug coverage usually comes from a PDP, and for Low-Income Subsidy (LIS) enrollees, certain PDPs are the only way to get premium-free coverage. PDP availability is shrinking; average options dropped from 30 in 2021 to 14 in 2025. While the average benchmark LIS plan options went from 8 to just 2. Meanwhile, MAPD options have grown from 27 to 34.

Key 2026 Changes

• Out-of-Pocket Max: $2,100 (up from $2,000)
• Deductible: $615 (up from $590)
• Insulin/Vaccines: $35 monthly cap for insulin, $0 for ACIP vaccines remain
• Prescription Payment Plan: Auto-re-enrollment unless opted out
• Premium Stabilization: Subsidy drops to $10/month; cap on annual premium hikes rises to $50; risk corridors end
• Base Premium: $38.99 max (up from $36.78)
• Drug Price Negotiations: First year of capped prices for 10 high-cost drugs
• Risk Adjustment: Updated to reflect negotiated prices and other changes

If you are an agent who is ready to join the team at Crowe; click here for an online contract.

What’s at Stake

If PDP choices keep declining, traditional Medicare could become less practical; especially in rural areas. Rising deductibles and premiums may be offset by negotiated drug savings, but market stability will be crucial to ensuring affordable coverage.

Medicare PDPs: 2025 vs. 2026 at a Glance

Bottom Line

The 2026 Medicare PDP landscape is about more than just new costs and benefit structures. It’s about the balance between traditional Medicare and Medicare Advantage, and whether beneficiaries, especially in rural America, will have access to affordable and adequate drug coverage. Reviewing plans annually, staying informed about legislative changes, and understanding the shifting market dynamics is key for beneficiaries and agents alike.

Agents; stay up-to-date on events and information – click here

Understanding Your Medicare Plan ANOC: Why it Matters

If you have a Medicare Advantage (Part C) plan or a Medicare Part D prescription drug plan, you’ll receive an Annual Notice of Change (ANOC) every fall. While it might be tempting to toss it aside with other “Medicare mail,” Understanding your Medicare Plan ANOC is important. It explains changes to health coverage, costs, and benefits for the upcoming year.

What Is an ANOC

The ANOC is a letter both Medicare Advantage and Part D plan are required to send enrollees by September 30. It outlines any changes the plan will make for the next calendar year, starting January 1. Even if enrollees are happy with their current coverage, these changes can directly impact what they pay and the care they receive.

The ANOC will compare the current year’s benefits, costs, and coverage with what they’ll be next year, including:

• Monthly premium changes
• Copays and coinsurance updates
• Deductible adjustments
• Changes to your provider network (doctors, specialists, hospitals)
• Changes to your drug formulary (which prescriptions are covered and how much they cost)
• Any added or removed benefits like dental, vision, hearing, or fitness programs

Why Is the ANOC Important

The ANOC is an early warning system for how coverage will look in the year ahead. Ignoring it can lead to unpleasant surprises like; your doctor is no longer in-network or prescription costs have gone way up.

By reviewing the ANOC carefully, you can:

1. Spot coverage gaps. Make sure medications, providers, and benefits are still covered next year.
2. Avoid unexpected costs; premiums, copays, and deductibles can increase.
3. Compare other plan options. If you don’t like the changes, you can explore new plans during the Medicare Annual Enrollment Period (AEP), which runs from October 15 to December 7.
4. Plan ahead; knowing changes in advance allows you to budget for new costs or switch to another plan before the year starts.

Agents watch a quick YouTube video on AEP marketing rules

What to Do When You Get Your ANOC

1. Open it immediately. Don’t let it sit in a pile of unopened mail.
2. Review every section. Pay close attention to drug coverage, provider networks, and cost changes.
3. Make a comparison chart. List 2025 vs. 2026 benefits and costs to see differences clearly.
4. Ask questions. Call your plan or talk to a licensed Medicare agent if you need clarification.
5. Take action during AEP. If the changes aren’t favorable, you can switch to a new plan.

Bottom Line

The ANOC is more than just a piece of Medicare paperwork; it’s a guide to understanding how your plan will serve you next year. Reviewing it now could save you money, protect your access to care, and ensure you have the coverage you truly need. The best way to get the coverage you need is to speak with a licensed Medicare agent who can go over all your options.

Agents stay updated on agent events and information – click here

If you are an agent who is ready to join the team at Crowe – click here for online contract.

Medigap Plan N vs Plan G: Which Is Right for You

When shopping for a Medicare Supplement (Medigap) plan, there are many options. Plan G and Plan N are two of the most popular choices for people looking to fill in the coverage gaps of Original Medicare. While they share many similarities, there are key differences in cost, coverage, and how they handle out-of-pocket expenses. Understanding Medigap Plan N vs Plan G can help you choose the plan that best fits your healthcare needs and budget.

What Medigap Plans Have in Common

Both Plan G and Plan N are standardized Medicare Supplement plans, meaning the basic benefits are the same no matter which insurance company offers them. With either plan, you get:

• Coverage for Medicare Part A coinsurance and hospital costs (after the beneficiary uses up Medicare’s benefits) for up to 365 days
• Coverage for Part B coinsurance or copayment (with exceptions for Plan N – explained below)
• Blood coverage (first 3 pints per year)
• Part A hospice care coinsurance or copayment
• Skilled nursing facility coinsurance
• Part A deductible
• Foreign travel emergency coverage (up to plan limits)

Key Differences Between Plan G and Plan N

1. Part B Excess Charges

• Plan G: Covers 100% of Medicare Part B excess charges (extra costs you may be billed if your provider doesn’t accept Medicare’s standard payment).
• Plan N: Does not cover Part B excess charges; if your provider bills them, you’ll have to pay out of pocket.

2. Office Visit & ER Copays

• Plan G: No copays for office visits or ER (after Medicare pays its share).
• Plan N: You may pay up to $20 for some doctor visits and up to $50 for emergency room visits (waived if admitted to the hospital).

3. Monthly Premiums

• Plan G: Generally has higher monthly premiums because it covers more.
• Plan N: Often has lower monthly premiums but requires more cost-sharing through copays and the possibility of excess charges.

4. Part B Deductible

• Both plans require you to pay the annual Medicare Part B deductible before coverage kicks in (for 2025, it’s $257).

Watch our YouTube video on Medicare Advantage vs Medicare Supplements

Which Plan is The Best Fit

• Choose Plan G if:
  • You want the most comprehensive coverage available to new Medicare enrollees.
  • You prefer predictable costs and don’t want to worry about excess charges or visit copays.
  • You see specialists who may charge more than Medicare’s approved amount.
• Choose Plan N if:
  • You want a lower monthly premium and are okay with occasional copays.
  • You typically see Medicare-assigned doctors who don’t bill excess charges.
  • You’re healthy, visit doctors less often, and want to save on monthly costs.

Both Plan G and Plan N are strong options that can protect you from high out-of-pocket costs not covered by Original Medicare. The right choice depends on how often you use healthcare services, whether your providers accept Medicare’s payment terms, and how much you want to pay each month in premiums versus at the point of care.

When comparing, it’s smart to enlist the help of a licensed Medicare agent who get quotes for both plans from multiple carriers. Please note: premiums vary by carrier even though the benefits are standardized.

If you are an agent who is ready to join the team at Crowe; click here for online contract.

Agents don’t miss important events and information; click here to learn more

Changing Medicare Supplement Plans: What to Know Before You Switch

Medicare Supplement (Medigap) plans are a great choice for covering the portion of out-of-pocket costs that Original Medicare doesn’t. However, as health needs and financial situations change, beneficiaries might consider changing Medicare supplement plans. Whether it’s to reduce premiums or adjust coverage, making a change requires some thought and planning.

Here’s what to keep in mind when considering a change to Medicare Supplement coverage.

Why People Change Medigap Plans

There are several reasons why someone might decide to change their Medigap plan:

• Overpaying for coverage: The current plan might offer more coverage than needed, meaning the policyholder may not use as much coverage as much as expected.
• Needing additional benefits: Health needs can change, and a different plan may provide better or more suitable coverage.
• Shopping for a better rate: Even if the benefits remain the same, switching to a different insurance carrier offering the same plan at a lower premium makes sense.
• Company dissatisfaction: Some beneficiaries want to change to a new insurer due to customer service or other experiences.

When You Can Switch

Changing Medigap plans isn’t quite as simple as enrolling in Medicare for the first time. There are only a few scenarios when someone can switch plans without facing potential roadblocks:

• During their six-month Medigap Open Enrollment Period: This period starts the month they turn 65 and are enrolled in Medicare Part B. During this time, they can buy any Medigap plan offered in their state or switch plans. Insurance companies cannot deny coverage based on health.
• 30 day free look period: After purchasing a new Medigap policy, you have 30 days to decide if you want to keep it. This allows beneficiaries to compare other plans with their your current plan. 
• With guaranteed issue rights: These are special protections that allow someone to buy certain Medigap plans without medical underwriting. Common situations that trigger guaranteed issue rights include losing employer coverage or moving out of a plan’s service area. However, there are currently 4 states that offer guaranteed issue rights regardless of the circumstance.

Please note: A new Medigap policy doesn’t automatically cancel the old one the way Medicare Advantage and PDP plans do. It is best not to cancel your old Medigap policy until you are sure you want to keep the new one.

Watch a YouTube video on Medicare Supplement underwriting.

Outside of the situations listed above, beneficiaries may need to go through medical underwriting to enroll in a new Medigap plan.

Understanding Medical Underwriting

Medical underwriting is a review process insurers use to assess an applicant’s health history and current conditions. Based on this review, a company can:

• Approve or deny the application.
• Charge a higher premium.
• Apply a waiting period for coverage of pre-existing conditions.

If a person applies for a Medigap plan outside their Open Enrollment Period and without guaranteed issue rights, their application could be declined based on health.

One common underwriting consideration is tobacco use. Smokers often face higher premiums, even if they are otherwise in good health.

No Waiting Period to Switch

There’s a common misconception that people have to keep their Medigap plan for a set amount of time before switching. The truth is, once someone has a Medigap policy, they can apply for a new one at any time. As long as they’re willing to go through underwriting if required.

Switching Medicare Supplement plans isn’t something to rush into, but with the right timing and a good understanding of the process, it can be a good idea for your health and finances. Whether it’s finding more appropriate coverage or simply lowering monthly costs, reviewing options regularly ensures your Medicare Supplement plan continues to meet your needs. It is best to speak with a licensed Medicare agent who can guide you through the options and find the best fit for your needs.A

If you are an agent who is ready to join the team at Crowe; click here for online contract.

Agents helping clients navigate this process; be sure they understand the importance of timing and potential underwriting challenges. They must understand how their health status could impact their options.

Stay up-to-date on agent events and information; click here.

Adding Ancillary Products to MA Sales – Why Agents Should Consider It.

Medicare Advantage (MA) plans have been attractive to beneficiaries because of their low or $0 premiums and extra benefits like dental, vision, hearing, and OTC allowances. However, changes are coming in 2026 that may make those extras less generous; or even disappear in some plans. This shift creates a perfect opportunity for agents to make additional sales by adding ancillary products to MA sales to fill these gaps.

Why Ancillary Products Matter in 2026 and Beyond

CMS’s recent updates, combined with economic pressures on carriers, mean some MA plans will scale back or remove certain supplemental benefits starting in 2026. For example, dental allowances might shrink, hearing aid coverage could become more limited, and OTC card values might drop. These changes could leave clients with unexpected out-of-pocket expenses for everyday healthcare needs.

By offering ancillary products alongside MA plans, agents can ensure clients still have access to comprehensive coverage while also boosting retention and cross-sell opportunities.

Types of Ancillary Products That Fit Well

When pairing ancillary products with Medicare Advantage plans, focus on coverage areas where benefits may be reduced or absent:

1. Dental Insurance
   • Why it works: Standalone dental plans often have broader provider networks and higher annual maximums than MA dental riders.
   • Example: A plan offering two cleanings per year, plus $1,500–$2,000 toward major services like crowns and dentures.
2. Vision Plans
   • Why it works: Even if MA plans include vision, it’s often limited to a small annual allowance for glasses or contacts.
   • Example: A vision plan that covers annual exams, multiple pairs of glasses, and larger frame allowances.
3. Hearing Plans
   • Why it works: MA hearing coverage often only includes one device every few years at a fixed copay, and choices can be restricted.
   • Example: A plan offering coverage for top-tier hearing aids, rechargeable batteries, and annual testing.
4. Hospital Indemnity Insurance
   • Why it works: Helps offset inpatient hospital costs, which are often the largest out-of-pocket expense for MA members.
   • Example: A policy that pays $200–$300 per day for each day hospitalized, plus an ambulance benefit.
5. Cancer, Heart Attack, and Stroke Plans
   • Why it works: MA plans cover treatment, but beneficiaries may face significant copays, travel expenses, and lost income. Learn more about critical illness insurance.
   • Example: A lump-sum policy that pays $10,000–$20,000 upon diagnosis, with funds that can be used however the client chooses.
6. Final Expense(Life Insurance)
   • Why it works: Provides peace of mind for covering funeral costs, especially for clients on fixed incomes.
   • Example: A $10,000–$15,000 whole life policy with simplified underwriting.

How to Position Ancillary Products

When discussing changes to MA benefits, avoid fear-based selling. Instead, focus on ensuring clients have complete and predictable coverage:

• Review their 2026 Annual Notice of Change (ANOC) for benefit reductions.
• Explain how ancillary products can “lock in” richer benefits regardless of MA plan changes.
• Offer bundled solutions such as a dental + vision package or a hospital indemnity + cancer plan combination.

Watch our YouTube video- Why and How to Sell Ancillary with Medicare in 5 Minutes

The Takeaway

As MA supplemental benefits become less generous in 2026, ancillary products will play a bigger role in protecting clients’ health and finances. By adding these products to your Medicare Advantage sales strategy, you’ll not only provide better coverage but also strengthen client relationships and create new revenue streams.

Medicare agents who want to join the team at Crowe, click here

Don’t miss industry events and information; click here to learn more.

Now is the time to prepare; review your carrier contracts, identify gaps in MA coverage, and be ready to present clients with options that keep their healthcare truly comprehensive.

Medicare Advantage VBID Termination: What Agents Need to Know

The Centers for Medicare & Medicaid Services (CMS) announced the Medicare Advantage VBID termination. The Value-Based Insurance Design (VBID) Model will officially end after the 2025 plan year. This marks the end of a decade-long initiative aimed to innovate care delivery and cost management in Medicare Advantage. For agents, brokers, and plan sponsors, it’s important to understand what this change means and how to prepare.

A Quick Recap: What Was the VBID Model

Launched in 2017, the VBID Model was designed to test new approaches to delivering Medicare Advantage benefits. Its goal was to improve health outcomes and reduce costs. This allowed plans to tailor benefits based on chronic conditions, offer enhanced supplemental benefits, and experiment with cost-sharing structures that promoted high-value care.

Over time, the model evolved to include features like:

• Chronic Condition Special Needs Plan (C-SNP) enhancements
• Reduced or waived cost-sharing for high-value services
• Incentive programs for beneficiaries
• Expanded telehealth access
• Integration of Medicare hospice benefits (starting in 2021 as part of a separate Hospice Benefit Component pilot)

Are you ready to join the team at Crowe; click here for online contract.

Why Is CMS Ending the Model

Although VBID showed promise in some areas, CMS reported mixed results in measurable improvement in cost savings and health outcomes. Despite some plans reported success, the model overall did not produce consistent, scalable results that justified its continuation beyond 2025.

The separate Hospice Benefit Component, a key aspect of the VBID experiment since 2021, will also end in 2025. CMS plans to use the lessons learned from this model to inform future policy and innovation strategies.

What This Means for Agents and Beneficiaries

If you’ve worked with clients enrolled in VBID-participating Medicare Advantage plans, now is the time to start tracking changes for 2026. Although the VBID Model is ending, plans may still continue some of the supplemental and chronic condition benefits on their own; just outside of the CMS demonstration model.

Here’s what to keep in mind:

• No disruption for 2025: Plans participating in VBID will continue as usual for the rest of the plan year.
• Prepare for benefit shifts in 2026: Expect changes in cost-sharing structures, supplemental benefits, and chronic condition management tools once the model concludes.
• Watch for new CMS innovations: While VBID is ending, CMS may introduce new pilots or value-based initiatives influenced by VBID findings.

The loss or reduction in benefits makes this a great time to put your cross selling skills to the test. Find out what products you can offer clients that will provide they coverage they need.

Watch a YouTube video on Cross selling

The sunsetting of the VBID Model is a significant development for the Medicare Advantage landscape. As an agent, staying proactive by reviewing carrier updates, analyzing plan adjustments, and educating clients about any changes will be critical. Although one model is ending, the pursuit of value-based care in Medicare is far from over.

Stay up-to-date on agent events and information; click here to learn more.

Stay tuned for more CMS announcements and be ready to pivot as the industry evolves.

Medicare Educational Event Guidelines – CMS Rules for 2026

As an agent, you will find that hosting an educational event is a great and inexpensive way to get out there and meet potential clients. However, it is imperative that you understand Medicare educational event guidelines before you do anything.

Define: Educational Marketing

CMS draws a firm line:

• These events must be “educational” in name and intent, not promoting a specific plan, carrier, or agent.
• Avoid mentioning brand names, plan details, incentives, or statements such as “call me to enroll.”
• Agents also must not imply in any way that they work for Medicare itself.

Must Include Event Disclaimers

Advertisements and invites must clearly state:

• “For accommodations of persons with special needs at meetings call [insert phone and‑TTY number].”
• “This event is for educational purposes only and no plan‑specific benefits or details will be shared.”

Content & Tone: Fact‑Based & Neutral

• Cover Medicare basics; Parts A, B, C, D, eligibility, enrollment windows, general plan types.
• Share objective tools, e.g., comparisons, eligibility calculators, and CMS (Centers for Medicare & Medicaid Services) resources.
• No steering: Personal recommendations or showing plan-specific premiums/benefits are prohibited.

Compliant Location & Registration

• Host events in public venues (e.g., libraries, community centers); not in private offices or health‑care settings, unless you use a common area.
• You may use a sign in sheet, however attendee use has to be optional.
• Be sure to register your event with the plan sponsor/MA organization if required (per MA/Part D compliance rules).

No Sales or Enrollment Activities

• Sales-focused tactics are forbidden; no enrollment scripts, plan comparisons, or benefit highlights.
• Do not take a SCOPE of appointment.
• It’s OK to show general enrollment periods and eligibility rules, but not to finalize or process enrollment.

Watch a YouTube video on Medicare Educational Seminar Best Practices

What agents can do

• Distribute generic materials such as business replay cards for attendees to request you contact them, but do not provide plan brochures or enrollment forms.
• Provide a light snack; keep in mind the value of the food must not exceed $15 per person.
• Offer promotional items as long as their value is $15 or less per person. Make sure they don’t include any plan information. They can however, include a carrier name, logo or toll free number.
• Provide your business cards for anyone who may want to contact you at a later date to schedule an appointment.
• Answer general questions; do not discuss specific plan details.

2026 CMS Rule Updates: What Agents Should Know

Expanded ADVERTISING Definition

For 2026, CMS is broadening what counts as “marketing.” Any general message that could sway enrollment now requires pre‑approval from CMS.
That means even “purely educational” ads could get flagged; plan carefully.

Click here to view the CMS 2026 fact sheet for the proposed final rule

Agents as Fiduciaries

Following the Senate Wyden report, there’s talk of requiring brokers to act as fiduciaries, disclose compensation, and limit lead-gen tactics. CMS may follow up, so transparency is key.

AI & Marketing Guardrails

CMS is reviewing proposals to ensure AI tools used in marketing are fair, transparent, and not deceptive. If you use chatbots or scripts, make sure they’re compliant.

CMS and IRA‑Driven Part D Changes

Though not directly event-related, these changes may impact your educational content:

• New Prescription Payment Plan (PPP) options—agents should know monthly cap letter tactics.
• Drug cost-sharing updates (insulin, vaccines)—beneficiaries now get these at $0 through Part D.

Agents stay up-to-date on the latest events and information

Best Practices for Agents

What Agents Should Do Next

1. Review and update event invites to include disclaimers and explicitly label them as educational.
2. Audit presentation materials to ensure neutral content; avoid any plan-specific information or persuasive language.
3. Train your team on the updated 2026 rules: no endorsements or marketing disguised as education.
4. Pre-submit ads if they could influence plan choice; especially media buys or mailers.
5. Stay informed on regulatory changes regarding fiduciary status and AI tools.

If you are ready to join the Crowe team; click here for online contracting.

In 2026, CMS is cracking down on the gray line between education and marketing. Agents must commit to clear, plan-neutral, fact-based events backed by proper disclaimers, transparent content strategy, and due diligence in marketing approach. Staying well-prepared now lays the foundation for trust, authority, and compliance down the road.