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TRICARE and Medicare Coverage: How the Two Work Together

Both agents and military retirees need to understand how TRICARE and Medicare coverage works in tandem. While both programs provide robust healthcare coverage, the rules around enrollment, coordination of benefits, and plan options may be confusing.

In this post, we’ll break down what TRICARE is, how it works with Medicare, key eligibility requirements, and what agents and beneficiaries need to know to ensure continuous and cost-effective coverage.

What Is TRICARE

TRICARE is the health care program for:

• Uniformed service members (active duty and retired)
• Their families
• National Guard/Reserve members
• Survivors and some former spouses

Administered by the Defense Health Agency (DHA), TRICARE provides coverage similar to private insurance plans and includes prescription drug benefits.

When a TRICARE Beneficiary Becomes Medicare-Eligible

When a TRICARE beneficiary turns 65 (or qualifies for Medicare earlier due to disability), they typically must enroll in Medicare Part A and Part B to maintain their TRICARE coverage.

Once they enroll in Medicare, TRICARE becomes TRICARE for Life (TFL).

What Is TRICARE For Life (TFL)

TRICARE for Life is the coverage that kicks in after a beneficiary becomes eligible for Medicare and enrolls in both Part A and Part B. TFL acts as a secondary payer to Medicare. Here’s how it works:

• Medicare pays first (as the primary insurance)
• TFL pays second, covering most or all of the remaining costs
• Out-of-pocket costs are minimal or nonexistent for covered services

Important: If a TRICARE beneficiary does not enroll in Medicare Part B, they will lose TRICARE coverage, unless they are an active-duty service member or family member of one.

Agents, click here to see what you need to know before a Medicare sale

Coverage Details: Medicare TRICARE for Life

Service	Medicare Pays	TFL Pays	Beneficiary Pays
Doctor visits	80%	Remaining 20%	$0 (in most cases)
Hospital stay	Medicare-approved	TFL covers deductible	$0
Prescription drugs	N/A	TFL (through Express Scripts)	Varies (copays)
Services not covered by Medicare (e.g., overseas)	N/A	TFL may pay	May vary

Can TFL Beneficiaries Enroll in Medicare Advantage

Technically, yes; TFL beneficiaries can enroll in a Medicare Advantage (MA) plan, but this often creates coverage conflicts and doesn’t offer cost savings.

Agents should caution beneficiaries:

• TFL does not coordinate well with MA plans.
• Some services covered by TFL may be denied if the MA plan doesn’t approve them.
• MA plans may interfere with how TFL pays claims.

Most beneficiaries are better off staying with Original Medicare + TRICARE for Life.

Do TFL Beneficiaries Need Medicare Part D

No, TFL includes a robust pharmacy benefit through Express Scripts. Enrolling in a separate Medicare Part D plan may result in:

• Loss of TRICARE pharmacy coverage
• Unnecessary monthly premiums
• Coordination issues

Agents: When working with TRICARE beneficiaries, always ask if they use the Express Scripts program before discussing Part D options.

Key Points for Medicare Agents

• Do not sell Medicare Advantage or Part D plans to TFL beneficiaries without reviewing the consequences.
• Always verify TRICARE status before recommending plan changes.
• Turning 65 is a triggering event that requires Medicare Part A & B enrollment to keep TRICARE.
• TFL works best with Original Medicare not Advantage plans.
• Help clients plan for premium costs; Medicare Part B still has a monthly premium, even with TFL.

Agents; if you are ready to join the team at Crowe, click here for online contracting

Key Takeaways for Beneficiaries

• Enroll in Medicare Part A and B when eligible to keep your TRICARE benefits.
• TRICARE for Life + Medicare offers comprehensive, low-cost healthcare.
• Avoid Medicare Advantage or Part D unless you understand the impact on your TRICARE benefits.
• You do not need Medigap; TFL acts as your Medicare supplement.

For military retirees and their families, TRICARE for Life is a valuable benefit that pairs seamlessly with Medicare; when used correctly. As an agent, your role is to educate and protect beneficiaries from making decisions that could disrupt their healthcare.

Click here for agent events and information

Whether you’re a veteran trying to understand your coverage or an agent assisting a retired service member, remember: when in doubt, stick with Original Medicare + TRICARE for Life.

Permission to Contact for Medicare Sales: What Agents Need to Know

As a Medicare agent, staying compliant with CMS marketing guidelines is critical. One of the most important aspects of compliance is obtaining Permission to Contact for Medicare sales (PTC) from potential beneficiaries before initiating sales calls or marketing activities. Failing to do so can result in regulatory violations, fines, and loss of certification with carriers.

In this blog, we’ll break down what Permission to Contact is, how to obtain it,and CMS rules that apply.

What Is Permission to Contact (PTC)

PTC is a CMS-required process that ensures beneficiaries give express consent before a Medicare agent can reach out to discuss plan options, answer questions, or schedule appointments. This rule protects Medicare beneficiaries from unsolicited contact and promotes ethical sales practices.

Crowe/Pinnacle agents can access online tools that help agents gather important client information including PTC with RetireFlo for Connecture or Sunfire’s BlazeSnyc:

Watch a video on RetireFlo for Medicare producers: Obtain client scopes, PTC, drug & doctor lists

Take a look at how the Sunfire BlazeSync customer intake form works

CMS Guidelines for Permission to Contact

According to CMS Medicare Communications and Marketing Guidelines (MCMG), agents may not:

• Cold call beneficiaries.
• Leave marketing materials in common areas (e.g., lobbies or libraries) to collect leads.
• Approach beneficiaries in healthcare settings or parking lots.

Agents must have documented permission from the beneficiary prior to outreach, unless the beneficiary initiates the contact.

Important: The PTC Permission to Contact form expires after 12 months or once it’s purpose has been fulfilled. If you need to contact the beneficiary after the original PTC expires, you must obtain a new one.

Acceptable Ways to Obtain Permission:

1. Permission to Contact (PTC) Form
2. Scope of Appointment (SOA) form
3. Inbound phone call from the beneficiary
4. Online request form (such as a lead form on your website)
5. Text or email initiated by the beneficiary
6. Business reply cards (BRCs)
7. Event sign-in sheets (when clearly marked as giving permission to be contacted)

Once permission is granted, it only applies to the scope and method defined. For example, if a beneficiary gives you permission to call about Medicare Advantage plans, you can’t use that to market life insurance or annuities.

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What Must Be Included in a PTC Form

A compliant Permission to Contact form should include:

• Beneficiary name
• Date
• Type of contact permitted (e.g., phone, email)
• Reason for contact (e.g., Medicare Advantage plan information)
• Statement that the individual is not obligated to enroll
• Signature or consent checkbox (if digital)

The form must also make it clear that responding is optional and not a condition of enrollment.

Permission to Contact Form

First Name: ____________________
Last Name: ____________________
Phone Number: ____________________
Email (optional): ____________________
Preferred Contact Method: ☐ Phone ☐ Email
Reason for Contact:
☐ I would like to be contacted by a licensed insurance agent to discuss Medicare Advantage and/or Prescription Drug Plans.

By completing this form, you agree that a licensed sales agent may contact you about Medicare plan options. You are under no obligation to enroll. This is a solicitation for insurance.

Signature: ____________________
Date: ____________________

Note: Agents should keep a copy of all PYTC forms for 10 years as art of their CMS compliance record.

When you Do Not Need a PTC

Although there are strict rules regarding client communication, there are exceptions when the contact is for ongoing client communications. Agents can contact existing clients about other products as long as the have an active business relationship. You can also contact plan enrollees with information on their coverage as long as you are listed as AOR.

Digital Lead Forms and Compliance

If you use online marketing to generate leads, your form must:

• Clearly indicate that a licensed agent will be contacting the user
• Include disclaimers like: “By submitting this form, you agree to be contacted by a licensed sales agent by phone, email, or text message about Medicare plan options. You are not obligated to enroll.”
• Ensure proper data encryption and opt-out procedures

Click here to stay updated on agent events and information

Getting Permission to Contact is not just a CMS requirement; it’s a trust-building opportunity. It shows respect for your client’s privacy and helps you build a compliant, professional reputation.

Always follow the most current CMS guidelines (as they can update annually), and never cut corners when it comes to consent. Remember, ethical practices protect both your business and your clients.

Prescription Discount Cards And Medicare

Even with Medicare Part D or a Medicare Advantage plan that includes drug coverage, many beneficiaries still find themselves facing high out-of-pocket costs for certain medications. Some drugs may carry expensive copays, while others may not be covered by your plan at all. That is when beneficiaries might alternate using prescription discount cards and Medicare Part D to cover their costs.

Fortunately, there are discount prescription programs that can offer real savings; even for those enrolled in Medicare. In this post, we explore how cards like GoodRx, SingleCare, and Glic work, and when it may make sense to use them instead of your Medicare plan.

Prescription Discount Cards

Prescription discount cards and programs are free tools that help consumers pay less for medications by accessing negotiated rates at participating pharmacies. These cards are not insurance; they’re a form of cash payment assistance.

A few of the most popular programs include; GoodRx, SingleCare and a more recent option; Glic. These programs provide price comparisons of specific medications across local pharmacies. The programs all work in a similar manner; although one may offer a better price on a specific medication than another. Each program provides access to the discount with either digital, printable coupons or discount cards.

Each program allows the consumer to pay the discounted rate out of pocket, bypassing their insurance. This sometimes results in lower costs than a Medicare Part D copay or coinsurance, especially for medications not on your plan’s formulary.

Learn about the Medicare prescription payment program – watch a quick YouTube video

When Medicare Beneficiaries Might Use a Discount Card

There are specific scenarios where it makes sense to use a discount program rather than Medicare Part D or Medicare Advantage drug coverage:

1. The medication isn’t covered (non-formulary)

If the plan doesn’t include a drug on its formulary, or it’s in a very high-cost tier, a discount card may offer a lower out-of-pocket price.

2. During the deductible phase

In 2025, most Medicare Part D plans may have an annual deductible (up to $590). During this phase, the beneficiary pays 100% of the cost of medications classified as tier 2 or 3 as well as higher tiers, depending on the specific plan they are enrolled in. A discount card may offer a lower price than the plan’s retail cost during this period.

Of course, the beneficiary may eventually have to pay the deductible anyway depending on their prescriptions.

3. The plan copay is higher than the discount price

For brand-name or specialty drugs in higher tiers, your Medicare plan’s copay may be more than the out-of-pocket cost using a discount program.

Please keep in mind: these programs do not usually cover brand name drugs better than your Medicare plan, but it never hurts to check.

Important Considerations

• Purchases with discount cards do NOT count toward your Medicare Part D out-of-pocket spending (TrOOP)
  If you use a discount card, your payment will not help you progress toward your deductible or maximum out-of-pocket limit.
• You can’t use both Medicare and a discount card at the same time
  It’s one or the other; tell the pharmacy to process it either through your insurance or the discount card. Most pharmacies will check to see which price is better if you ask them to.
• Prices vary by pharmacy
  Always check the card’s website or app to compare pharmacy prices before filling a prescription.

How to Use a Discount Program

1. Search for the drug on the program’s website or app(be sure you enter the correct dose and amount of each medication)
2. Compare prices across pharmacies in your area
3. Show the coupon or card to the pharmacist before paying
4. Pay out of pocket at the discounted rate

Tip: Keep a screenshot or printed copy of your discount code in case your phone doesn’t have service inside the pharmacy.

Medicare Agents

Encouraging clients to explore discount programs when appropriate can strengthen client trust and help with medication adherence. If a prescription is not covered, or too costly, these programs can be a smart short-term solution. Agents should always remind clients that discount purchases do not count toward Medicare drug spending.

Programs like GoodRx, SingleCare, and Glic Rx can provide real relief when Medicare drug costs are high, or when certain medications aren’t covered at all. They’re simple to use, free to access, and often a good backup when Part D coverage doesn’t go far enough.

Please remember; beneficiaries may be able to get a formulary exception if their medication is not on their plan’s formulary.

Agents who want to join the team at Crowe; click here for online contracting

Just remember: discount cards are not a replacement for a comprehensive drug plan, but they can be a smart tool in your healthcare savings toolbox.

If you are an agent who wants to stay updated on events and information, click here

2026 AHIP Certification Guide for Medicare Agents

Each year, Medicare agents must complete a series of certifications before they’re ready to sell to Medicare Advantage (MA/MAPD) or Prescription Drug Plans (PDPs) to their clients. One of the most important is the AHIP. Our AHIP 2026 certification guide should help you check this off your list.

The 2026 AHIP training is available on June 23, 2025, and it will cover any business written for the remainder of 2025 and all of 2026.

If you’re looking to stay compliant, contract with carriers, and be “Ready to Sell,” here’s everything you need to know to get started; including test tips, module breakdowns, discount info, and what happens if you do not pass.

What Is the AHIP and Why It’s Important

The AHIP (America’s Health Insurance Plans) certification is a CMS-compliant annual training course designed to ensure Medicare agents understand:

• The structure of Original Medicare
• How Medicare Advantage and Part D plans work
• Compliance and marketing rules
• Enrollment periods
• Fraud, waste, and abuse (FWA) prevention

Most MA/MAPD and PDP carriers, with a few exceptions (such as UnitedHealthcare, which has its own certification) require agents to pass AHIP. Completing it is often the first step toward certification with each carrier for the Annual Enrollment Period (AEP).

2026 AHIP Launch Date

• Course Available: June 23, 2025
• Covers: Remainder of 2025 and all of 2026
• Cost: $175 (discounts often available through major carriers)

Crowe/Pinnacle Financial Agents can receive a $50 discount by taking the course through PFSinsurance.com. Just log in, go to the Certifications tab, and scroll to the AEP Toolkit for the Pinnacle AHIP discount link.

2026 AHIP Test Tips

• The test includes 50 multiple choice questions
• Agents have 2 hours and 3 attempts
• Passing Score: 90%
• If you fail all three attempts, you must repurchase and retake the course
• Warning: Some carriers will not allow you to sell their plans for the year if you fail three times

Watch our AHIP Test Tips 2025 on YouTube

What’s in the AHIP Modules

The AHIP course is split into two main parts:

Part 1: Medicare Overview (5 Modules)

1. Module 1 – Overview of Medicare Program Basics: Choices, Eligibility and Benefits
2. Module 2 – Medicare Health Plans
3. Module 3 – Medicare PArt D: Prescription Drug Coverage
4. Module 4 – Marketing Medicare Advantage and Part D Pans
5. Module 5 – Enrollment Guidance Medicare Advantage and Part D Plans

Tip: Download the slides for all Modules. If you took the 2025 course, you do not have to complete all 5 modules, you can skip 1-3 (just do the review). You may only need to complete modules 4 & 5.

Because each module includes a 20-question practice test, it may not be a bad idea to go over all modules. The final exam questions are pulled directly from these quizzes. Pay close attention to any you got wrong to be sure you answer them correctly when it counts.

Part 2: Fraud, Waste & Abuse (FWA)

Part 2 of the AHIP certifications FWA consists of 3 Modules

1. Non-Discrimination Training; what qualifies as discrimination and what does not.
2. Medicare Fraud, Waste and Abuse; how to identify and report FWA, financial and ethical consequences and the impact of FWA.
3. General Compliance; legal tools and compliance requirements and who they apply to.

Each of these modules has a practice test and a final test when those are completed. You only need a score of 70 to pass this portion.

After You Pass: What’s Next

1. Download your AHIP certificate
2. Transmit your results to participating carriers through AHIP, or manually upload it to the carriers you are contracted with dashboards
3. Complete carrier-specific certifications for each MA or PDP product line

Helpful Reminders

• UnitedHealthcare (UHC) doesn’t require AHIP but does have its own certification
• AHIP 2026 is similar to 2025, but includes updates for new CMS rules, including changes related to Part D redesign and marketing compliance
• You must complete AHIP before you receive a RTS from most carriers even if you complete their certifications.

If you’re a new agent looking to join a supportive upline or an existing agent who wants to add a carrier to your existing contract:
Click here for online contracting

Getting AHIP-certified early is a smart move. It opens doors to carrier contracts, helps avoid delays, and gives you the confidence to serve your Medicare clients accurately and compliantly.

Click here to stay up-to-date on agent events and information.

Don’t wait until the last minute; take advantage of our AHIP 2026 tips, download the modules, and use the practice tests. Remember, three tries is all you get before you have to start over; so make your first try count!

Medicare vs. Employer Insurance: Which One Pays First

When you’re eligible for Medicare and also have employer-sponsored health insurance, things can get a little confusing. One question that comes up often: is Medicare or employer coverage primary?

The answer depends on employment status, the size of the employer, and the type of Medicare you have. Here’s what you need to know about how Medicare coordinates with employer coverage and who pays first.

Primary Payer

When you have more than one type of health coverage, the primary payer is the insurance that pays first for your healthcare services. The secondary payer may cover remaining costs, such as copayments, coinsurance, or deductibles.

Knowing which plan is primary ensures:

• Your claims are processed correctly
• You avoid unexpected bills
• You stay compliant with Medicare rules

General Rule: Employment Size Determines Priority

If You’re 65 or Older and Still Working

If your employer has 20 or more employees:

• Employer insurance is primary
• Medicare is secondary

If your employer has fewer than 20 employees:

• Medicare is primary
• Employer insurance is secondary

Note: The same rule applies if you’re covered under your spouse’s employer plan.

Watch a video on how Medicare works with employer coverage

Under 65 and Have Medicare Due to Disability:

If your (or your spouse’s) employer has 100 or more employees

• Employer insurance is primary
• Medicare is secondary

If the employer has fewer than 100 employees

• Medicare is primary

Retiree Coverage or COBRA

• Medicare is always primary
• Retiree plans and COBRA are considered secondary

In fact, if you delay enrolling in Medicare while on COBRA, you could lose COBRA coverage. Always sign up for Medicare Part B when first eligible to avoid penalties and gaps in coverage.

What About Veterans Benefits or TRICARE

If you have VA coverage, TRICARE, or other federal health benefits, the rules may differ:

• VA only covers care at VA facilities. If you go to a non-VA provider, Medicare pays first.
• TRICARE for Life acts as secondary coverage to Medicare for eligible military retirees.

Beneficiaries

• Don’t assume employer insurance will always pay first; check the size of the employer.
• Always inform Medicare and your employer plan that you have dual coverage so they can coordinate benefits properly.
• If Medicare is supposed to be primary and you haven’t enrolled in Part B, your employer plan may refuse to pay claims.

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Stay updated on the latest agents news and events

Medicare OEP Open Enrollment Period

The Medicare Open Enrollment Period (OEP) runs annually from January 1 to March 31. It is specifically for individuals already enrolled in a Medicare Advantage (Part C) plan as of January 1.

This period does not apply to those with Original Medicare (Part A and B) only; it’s strictly for Medicare Advantage plan members who may want to make a one-time change.

What Changes Can You Make During OEP

Those enrolled in a Medicare Advantage plan, can make one change during the OEP. The options include:

• Switching to a different Medicare Advantage plan, with or without drug coverage
• Dropping your Medicare Advantage plan and returning to Original Medicare, with the option to add a Part D prescription drug plan

Changes You Cannot Make:

• Switch from Original Medicare to a Medicare Advantage plan
• Enroll in Part D drug coverage if you’re on Original Medicare and missed your IEP or AEP
• Make multiple changes; OEP only allows one switch

Watch a video on Medicare enrollment periods

Why Use the OEP

Here are a few common reasons beneficiaries take advantage of the Medicare OEP:

• Their current Medicare Advantage plan doesn’t cover a needed medication or provider
• They discovered higher costs or restrictions after using the plan in January
• They had a change in health and want a different plan with better specialist coverage
• They were unaware of better plan options during the Annual Enrollment Period (AEP), which runs from October 15 to December 7

How Is OEP Different from AEP

Important Considerations

• If you switch to Original Medicare during OEP, you may not be guaranteed Medigap (Medicare Supplement) coverage; unless you’re in a trial right or qualify for a Special Enrollment Period.
• Any changes made during the OEP become effective the first day of the month after the change is made (e.g., a change in February takes effect March 1).
• It’s important to review coverage early in the year to determine if your current plan still meets your needs.

Work with a Licensed Agent

The Medicare OEP is a valuable but limited opportunity to make corrections or improvements to your coverage. If you’re unsure whether your plan fits your health needs or budget, speak with a licensed Medicare agent. They can help you compare options, check provider networks and drug formularies, and make confident decisions about your healthcare.

Agents; if you are ready to join a winning team, click here for Crowe contracting!

Stay updated on agent information and events, click here

Medicare Commissions 2026 for Medicare Advantage & PDP Plans

As the Medicare industry evolves, so do the rules and compensation guidelines set by CMS. For 2026, CMS has released updated Medicare commissions 2026 for Medicare Advantage (MA) and Prescription Drug Plans (PDPs). Every Medicare agent needs to be aware of the new amounts and the policy changes behind them.

Below is a breakdown of what’s changing and how it impacts your commissions heading into the 2026 Annual Enrollment Period (AEP).

2026 Maximum Commission Rates

Each year CMS sets a fair market value (FMV) for agent compensation. These rates represent the maximum allowable compensation carriers can pay agents for enrollments and renewals of Medicare Advantage and Part D plans.

Medicare Advantage (MA) Initial Compensation:

• National base: $694 (up from $626 in 2025) this is the rate for any state not listed below.
• Renewal compensation: $347 per renewal (up from $313)

Connecticut, Pennsylvania, District of Columbia:

• Initial compensation: $781
• Renewal: $391

California and New Jersey:

• Initial compensation: $864
• Renewal: $432

Puerto Rico and U.S. Virgin Islands:

• Initial compensation: $474
• Renewal: $237

Prescription Drug Plan (PDP) Compensation:

• Initial enrollment: $114 (up from $100 in 2025)
• Renewal: $57

These are maximums. Carriers are not required to pay this amount but may do so depending on their policies and agent contracts.

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Why CMS Raised MA Commissions

The substantial increase in MA commissions; particularly the national base, is part of CMS’s broader effort to:

• Align compensation with the increased workload and compliance obligations placed on agents
• Encourage transparency and fair practices in marketing and enrollments
• Reflect rising healthcare costs and inflationary trends

Watch a video on Medicare commission payment details

Compliance Remains Critical

With higher compensation comes increased scrutiny. CMS continues to crack down on misleading marketing, aggressive sales tactics, and non-compliant enrollments.

Key compliance reminders for 2026:

• Scope of Appointment (SOA) forms must be completed 48 hours before most marketing appointments
• Call recordings of all Medicare-related sales calls are still required
• Third-party marketing organizations (TPMOs) must clearly disclose affiliations and limitations of plan representation

As commissions rise, expect CMS and carriers to take a firmer stance on agent conduct, training, and documentation.

Stay updated on agent events and information

Agent Tips to Maximize Success

1. Stay current on training: Complete your AHIP and carrier certifications early.
2. Educate your clients thoroughly: Higher commissions can mean more scrutiny, make sure clients understand their options.
3. Build long-term relationships: Renewal commissions continue to rise, rewarding agents who support their clients beyond initial enrollment.
4. Diversify your offerings: Include PDPs and Medigap plans or ancillary benefits where appropriate; some clients may benefit more from a supplement and drug plan.
5. Leverage compliant marketing: Use CMS-approved marketing materials and ensure your lead generation efforts are transparent and ethical.

The 2026 updated commission amounts are great news for agents who work hard to serve the Medicare community. Higher commissions and a continued emphasis on compliance and ethics mean; it is a good time to refine your strategy, refresh your knowledge, and recommit to providing excellent service.

Understanding Medicare Coverage of Physical Therapy

Physical therapy can play a vital role in recovery from injury or illness, helping individuals regain strength, mobility, and independence. However, it can also be a time-consuming and costly process. If you’re a Medicare beneficiary, it’s important to understand Medicare coverage of physical therapy.

When Physical Therapy May Be Necessary

Physical therapy (PT) is designed to evaluate and treat conditions that limit the ability to function in daily life. The goals of PT may include:

• Restoring lost mobility or strength
• Slowing physical decline
• Managing chronic conditions
• Preventing further injury

Medicare Coverage of Physical Therapy

Most outpatient physical therapy services are covered under Medicare Part B, which includes:

• Medically necessary physical therapy
• Occupational therapy (OT)
• Speech-language pathology (SLP)

If you receive physical therapy during an inpatient stay (such as in a hospital or skilled nursing facility), Medicare Part A may cover those services as part of your inpatient benefits.

Medicare Advantage (Part C) members should refer to their plan’s Evidence of Coverage or contact the plan’s member services for specific benefits, as coverage may vary by plan.

Eligibility & Medical Necessity

For Medicare to cover physical therapy:

• The services must be medically necessary
• A doctor or healthcare provider must prescribe and supervise the treatment
• The patient must receive care at a facility that accepts Medicare assignment

Services must target a diagnosed condition and be part of a treatment plan with documented goals and progress reviews.

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Therapy Thresholds and the KX Modifier Rule (2025 Limits)

In 2018, Medicare eliminated the hard cap on therapy services, replacing it with a “soft cap” or threshold. This allows continued access to necessary care while tracking usage and ensuring services are medically necessary.

In 2025, the therapy thresholds are:

• $2,330 for combined Physical Therapy (PT) and Speech-Language Pathology (SLP) services
• $2,330 for Occupational Therapy (OT) services

Once a patient exceeds these thresholds, the provider must apply a KX modifier on Medicare claims to confirm that services continue to be medically necessary.

Important: These thresholds are not a hard limit. As long as therapy is medically necessary and properly documented, Medicare will continue to cover services beyond the threshold.

Stay updated on the latest agents events and information

What Will You Pay?

Under Medicare Part B:

• You pay the annual Part B deductible (which is $240 in 2025)

• After meeting the deductible, you’re responsible for 20% coinsurance of the Medicare-approved amount

If you have a Medicare Supplement (Medigap) plan, it may cover the 20% coinsurance. Be sure to confirm your provider accepts Medicare assignment, which ensures you’re not billed more than Medicare’s approved rates.

Agents watch a quick video on AEP Planning

Who Can Provide Covered Therapy Services?

To be covered by Medicare, therapy must be delivered by:

• A licensed Physical Therapist (PT)

• A licensed Occupational Therapist (OT)

• A licensed Speech-Language Pathologist (SLP)

These professionals must meet Medicare’s credentialing and billing requirements.

Documentation and Progress Tracking

For continued Medicare coverage, your therapy provider must:

• Track and document your progress

• Demonstrate ongoing medical necessity

• Review and update your care plan as needed

Active participation in your therapy plan and attending all scheduled sessions are key to both recovery and continued coverage.

With understanding and guidance, accessing the necessary physical therapy services is easy and comes without added financial stress. 

Beneficiaries enrolled in a Medicare Advantage plan should review plan-specific benefits or contact their Medicare agent or your plan’s customer service for details. 

Understanding the Different Types of Medicare Advantage Plans

Medicare Advantage (Part C) plans offer an all-in-one alternative to Original Medicare, often including additional benefits like dental, vision, hearing, and even prescription drug coverage. These plans are offered by private insurance companies approved by Medicare. Whether you’re a Medicare beneficiary or an agent helping clients make informed decisions, understanding the different types of Medicare Advantage plans is essential.

There are many types of Medicare advantage plans to consider when choosing coverage that best fits your needs. Here’s a breakdown of the main types of MA plans available:

HMO (Health Maintenance Organization) Plans

Key Features:

• Requires members to use a network of doctors and hospitals.
• Members must choose a Primary Care Physician (PCP).
• Referrals are usually needed to see a specialist.
• Most HMO plans include prescription drug coverage (Part D).

Best for: People who are comfortable with a coordinated care approach and staying within a specific provider network to keep costs low.

PPO (Preferred Provider Organization) Plans

Key Features:

• Offers more flexibility in choosing healthcare providers.
• You can see out-of-network providers, usually at a higher cost.
• No need to choose a PCP or get referrals for specialists.
• Often includes Part D prescription drug coverage.

Best for: Those who want the freedom to see any doctor or specialist without a referral and are willing to possibly pay a bit more for that flexibility.

SNPs (Special Needs Plans)

Key Features:

• Tailored for individuals with specific diseases, health conditions, or financial needs.
• Types include:
  • C-SNPs: For people with chronic conditions (e.g., diabetes, heart disease).
  • D-SNPs: For dual-eligible individuals (Medicare and Medicaid).
  • I-SNPs: For people in institutional care (like nursing homes).
• Always includes prescription drug coverage.
• Offers care coordination and case management.

Best for: Individuals with specific medical, financial, or living circumstances who need a personalized care approach.

PFFS (Private Fee-for-Service) Plans

Key Features:

• Allows you to see any Medicare-approved provider who agrees to the plan’s payment terms.
• No need to choose a PCP or get referrals.
• Some PFFS plans include drug coverage; others don’t.

Best for: People who want flexibility and are comfortable checking whether their provider will accept the plan’s terms.

POS (Point of Service) Plans

Key Features:

• A hybrid of HMO and PPO.
• You can go out-of-network for certain services, often with higher copays or coinsurance.
• Requires a PCP and referrals for specialists (when in-network).
• May include drug coverage.

Best for: Beneficiaries who like the care coordination of an HMO but want some out-of-network flexibility.

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MSA (Medical Savings Account) Plans

Key Features:

• Combines a high-deductible health plan with a savings account that Medicare deposits money into.
• Funds can be used to pay for qualified medical expenses.
• Does not include Part D coverage; must be purchased separately.

Best for: Those who prefer managing their own health savings and expenses and are comfortable with high deductibles.

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Choosing the Right Medicare Advantage Plan

When evaluating which type of plan is best for you or your client, consider:

• Provider access: Do you want to stay in-network or have more flexibility?
• Prescription needs: Is Part D coverage important?
• Cost preferences: Would you rather pay higher premiums for lower out-of-pocket costs or vice versa?
• Health conditions: Are there chronic conditions or Medicaid eligibility that might qualify for an SNP?

Each Medicare Advantage plan type offers different benefits, restrictions, and costs. Understanding these differences is the key to selecting the most suitable coverage.

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Medicare TrOOP Costs: What Beneficiaries and Agents Need to Know

When it comes to Medicare Part D prescription drug coverage, there’s one term that often causes confusion but plays a big role in how much a beneficiary pays: TrOOP. In this post, we explain Medicare Part D TrOOP Costs and their effect on the client’s costs for prescription medication.

Whether you’re a Medicare beneficiary trying to understand your coverage or a Medicare agent helping clients navigate their plans, understanding TrOOP is essential.

What Is TrOOP

TrOOP (True Out-of-Pocket) costs refers to the amount a Medicare beneficiary pays for covered prescription drugs before reaching catastrophic coverage under a Part D plan. These costs include deductibles, copays, and coinsurance for medications covered by the plan.

TrOOP is used to track a beneficiary’s spending so that Medicare knows when to move them through the different Part D coverage phases.

What Counts Toward Medicare Part D TrOOP Costs

Not everything a beneficiary pays will count toward TrOOP. Only qualified out-of-pocket spending applies. Here’s what counts:

• Annual deductible (if applicable)
• Copays and coinsurance for formulary drugs (covered by your plan)
• Payments made by:
  • The beneficiary
  • A family member
  • State Pharmaceutical Assistance Programs (SPAPs) or the Federal Government’s Extra Help Program.

What Doesn’t Count Toward Medicare Part D TrOOP Costs

Some expenses don’t count toward your TrOOP total, including:

• Monthly premiums for the Part D plan
• Drugs not covered by the plan (not on the plan’s formulary). Although, if the drug is approved via exception or appeal, it does count towards the TrOOP
• Over-the-counter (OTC) drugs
• Drugs purchased outside of the U.S.
• Payments by other insurance (e.g., employer group plans or TRICARE)

TrOOP and the 3 Phases of Part D

To understand how TrOOP affects drug costs, it helps to review the stages of Medicare Part D:

1. Deductible Phase
   • The beneficiary pays 100% of their drug costs until they meet the deductible.
2. Initial Coverage Phase
   • Beneficiaries pay about 25% of the cost for formulary drugs in the form of copays or coinsurance until they reach $2,000 out of pocket (the initial coverage limit).
3. Catastrophic Coverage Phase
   • After TrOOP reaches a set amount ($2,000 in 2025, increasing in 2026), the beneficiary pays $0 for covered drugs once they have hit the TrOOP under the new 2025 rules.

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Key Takeaways for Beneficiaries and Agents

• TrOOP helps Medicare track spending to determine when beneficiaries qualify for better cost-sharing.
• Only qualified out-of-pocket costs count.
• In 2025, TrOOP maxes out at $2,000; a major win for Medicare enrollees.
• Medicare agents should explain TrOOP carefully when helping clients compare drug plans or estimate yearly costs.

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