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When is a Referral Required – Which Medical Services Require a Referral

Navigating the healthcare system can sometimes feel overwhelming, especially when it comes to understanding when you need a referral to see a specialist. A referral is essentially a written order from your primary care provider (PCP) that allows you to receive care from another doctor, specialist, or healthcare service. But referrals aren’t always required, when is a referral required; that depends on the health insurance plan and the type of care needed.

Why Referrals Exist

Referrals are designed to coordinate care, avoid unnecessary tests, and ensure your treatment is medically appropriate. They also help insurance companies manage costs by making sure patients start with a PCP who oversees their overall health.

When a Referral is Required

Here are common situations where you’ll likely need a referral:

1. HMO (Health Maintenance Organization) Plans
   • Most HMO plans require you to have a referral before seeing a specialist.
   • Without a referral, the plan may not cover the service, leaving you responsible for the full cost.
2. Specialty Care
   • Services like dermatology, cardiology, orthopedics, and other specialist visits often need a referral under certain insurance plans.
3. Imaging and Diagnostics
   • Advanced tests such as MRIs, CT scans, or certain lab work may require a referral or prior authorization.
4. Out-of-Network Care
   • If your plan allows out-of-network services, you may need a referral and pre-approval for coverage.
5. Medicare Advantage (Part C) Plans
   • Many Medicare Advantage HMOs require referrals to see specialists.
   • PPO-style Medicare Advantage plans usually allow you to see specialists without referrals, though costs may be higher if you go out-of-network.

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When a Referral May Not Be Required

Not every plan or situation requires a referral. Examples include:

• PPO (Preferred Provider Organization) Plans – Generally, you can see specialists without a referral, but in-network providers will be more cost-effective.
• Emergency Care – True emergencies do not require a referral.
• Preventive Services – Annual wellness exams, certain screenings, and vaccinations are usually covered without a referral.
• Original Medicare – If you have Medicare Part A and Part B (without a Medicare Advantage plan), you typically do not need referrals to see specialists.

Watch a YouTube video on Medicare enrollment periods

How to Know if You Need a Referral

• Check Your Plan Documents – Your insurance card or plan booklet will outline referral requirements.
• Ask Your PCP – If you’re unsure, your primary doctor can confirm whether you need a referral for the service you’re seeking.
• Call Your Insurance Provider – The member services number on your card can clarify referral rules for your coverage.

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Why This Matters

Getting care without the proper referral could result in unexpected bills or denied claims. Knowing when referrals are required can save you time, money, and stress—and ensure your care stays coordinated across providers.

Using HSAs with Medicare: What Beneficiaries and Agents Need to Know

Health Savings Accounts (HSAs) are a valuable tool for people with high-deductible health plans (HDHPs), allowing them to set aside pre-tax dollars for qualified medical expenses. However, once Medicare enters the picture, the rules change. For Medicare beneficiaries and the agents who guide them, it’s important to understand how using HSAs with Medicare works. There are important changes when Medicare begins, so educating your clients help them use those funds wisely.

Can You Contribute to an HSA While on Medicare

The short answer: no.

Once someone enrolls in any part of Medicare (Part A, Part B, or both), they are no longer eligible to make contributions to an HSA. Because Medicare is not considered a high deductible health plan, The IRS prohibits contributions after Medicare enrollment.

Key timing note:

• Many people are automatically enrolled in Medicare Part A at age 65 if they are already taking Social Security benefits. This means their HSA contribution eligibility ends immediately.
• If a person delays Medicare enrollment (and Social Security benefits) while still working and covered by an employer-sponsored HDHP, they can continue contributing to their HSA until Medicare coverage begins.

Watch a YouTube video about Medicare and employer coverage

Using HSA Funds After Enrolling in Medicare

While contributions must stop, the good news is that HSA funds remain available for future use. Beneficiaries can use those dollars tax-free on a wide range of expenses, including many costs associated with Medicare.

Eligible Medicare-related expenses include:

• Medicare Part A, Part B, and Part D premiums
• Medicare Advantage (Part C) plan premiums
• Out-of-pocket costs like deductibles, copays, and coinsurance
• Dental, vision, and hearing expenses not covered by Medicare
• Prescription drugs (both covered and not covered by Medicare)

Important restriction: Beneficiaries cannot use HSA funds to pay for Medigap (Medicare Supplement) plan premiums.

Tax Benefits of Using an HSA with Medicare

• Tax-free withdrawals: As long as beneficiaries use funds for qualified medical expenses, withdrawals are tax-free.
• Penalty-free withdrawals after age 65: Even if funds are used for non-medical expenses, the 20% penalty is waived after age 65. However, the IRS taxes those withdrawals as regular income.

This flexibility makes HSAs a powerful retirement planning tool—especially for covering health costs, which typically rise with age.

Guidance for Medicare Agents

For agents advising clients, it’s helpful to remember:

1. Ask about employer coverage: If clients are still working past 65 and covered under an HDHP, delaying Medicare could allow them to continue building HSA savings.
2. Review timing carefully: Enrolling in Medicare Part A retroactively (up to 6 months) can affect HSA contribution eligibility and may trigger penalties if excess contributions are made.
3. Highlight the benefits of saved funds: Even if contributions stop, those HSA balances can play a big role in covering Medicare premiums and out-of-pocket costs.

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Agents; stay updated on events and information.

HSAs and Medicare don’t work together in the traditional sense; contributions must stop once Medicare begins. But the funds already in the account can provide significant financial relief for medical costs in retirement. For Medicare beneficiaries, understanding the rules ensures they maximize both their HSA and Medicare benefits. For agents, this knowledge is another way to bring clarity and value to client conversations.

Final Rule CY 2026

On April 4, 2025, CMS released the final rule CY 2026, covering Medicare Advantage (MA), Part D (Prescription Drug Plans), Medicare cost plans, and Programs of All-Inclusive Care for the Elderly (PACE). In this post, we go over some key points of the CMS final rule 2026 to keep agents up dated.

Key Provisions

• Prescriber and Prior Authorization Adjustments: MA plans can only reverse inpatient admission approvals if there’s clear evidence of fraud or error, preventing sudden post-approval denial
• Appeals Expansion: Decisions affecting appeals now apply if made during, after, or before services begin
• Insulin & Vaccine Cost-Sharing Protections: No deductible and capped cost-sharing (either less than or equal to $35 or 25% of price) for insulin; rules go live in CY 2026. Adult ACIP recommended vaccines under Part D do not charge cost-sharing or a deductible.
• Medicare Prescription Payment Plan: Monthly OOP drug payment options become standard. Automatic renewals apply unless beneficiaries opt out.
• Medicare Drug Price Negotiation Program: Pharmacies must enroll in CMS’ data Module. PDE submission timeline for selected drugs is shortened to 7 days (was originally 30).
• Medical Loss Ratio (MLR) Changes: Certain federal subsidies (selected drug subsidy, IRASA, etc.) are excluded from MA/Part D calculations
• Payment Updates: MA plan payments increased by 5.06% on average. This raises carrier reimbursement by over $25 billion. Because of late year FFS data inclusion, the effective growth rate grew to 9.04%.
• Full phase-in of medical-education cost adjustments in MA risk model

What Didn’t Make it Into the Final Rule

• Anti-obesity medication coverage remains excluded.
• No finalized rule on AI guardrails or formal health equity assessments

Implications for Medicare Agents

Plan Design and Marketing Impact

The improved payment rates and stronger benefits (e.g., capped insulin costs, free vaccines) make MA/Part D plans more attractive to beneficiaries—enhancing your ability to recommend compelling, cost-effective options.

Client Conversations and Value Messaging

You can emphasize zero cost-sharing for critical needs like adult vaccines and insulin, and promote payment flexibility via monthly prescription cost installment plans—boosting engagement with clients, especially those on tight budgets.

Administrative & Compliance Updates

• Prepare for stricter documentation requirements, especially for prescription payment plans and MLR-related tracking.
• Expect increased scrutiny on marketing practices, including proof that compensation adheres to CMS limits.

Watch a YouTube video on CMS Medicare Final Rule Proposal 2026

Compensation Boosts (Broker Commissions)

Although not part of the CMS final rule, standard compensation data from CMS shows a significant increase in 2026:

• MA Plans:
  • National initial commissions rise 10.9% (e.g., from $626 to $694).
  • Renewal commissions up 10.9% (e.g., $313 to $347).
  • In CT, PA, DC: initial rises to $781, renewal to $391
  • View a more detailed commission explanation – click here
• Part D Plans:
  • Initial commissions up 4.6% ($114).
  • Renewal commissions up 3.6% ($57)
• Sponsoring organizations must submit these updated commission rates to CMS and maintain payment records.

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Summary Final Rule CY 2026

Capped insulin costs, vaccine cost-sharing elimination, and flexible payment options empower agents to provide more affordable, client-focused solutions.

Higher broker commissions reward agents, but with greater compliance expectations.

Marketing oversight and fiduciary responsibility pressures are rising; agents must prioritize ethics and accuracy in representation. Agents should stay vigilant; future enforcement or reform may impact compensation and operational protocols.

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As an agent, your role is stronger than ever. Stay informed, compliant, and focused on client outcomes. Although 2026 promises to be a challenge, agents who put together a good strategy and work with integrity, can thrive while supporting clients’ health and financial well-being.

Part D Late Enrollment Penalties (LEP) Appeals: What Beneficiaries Need to Know

Missing the Medicare Part D Initial Enrollment Period (IEP) can lead to costly consequences. Medicare charges those who go more than 63 consecutive days without creditable prescription drug coverage Part D Late Enrollment Penalties. CMS will add the (LEP) to the Part D plan premium.

Fortunately, those who are assessed this penalty, have the right to appeal through the Part D LEP Reconsideration process. Here’s what beneficiaries and agents should know.

When Does the LEP Apply

A Late Enrollment Penalty is typically added when:

A beneficiary delays enrolling in a Part D plan during their Initial Enrollment Period, and they didn’t have other creditable coverage for 63 consecutive days.

If a Part D plan determines there is a lapse in creditable coverage, they must send a written notice explaining the penalty. This notice will include the LEP Reconsideration Request Form, which gives you the option to appeal.

Your Right to Appeal

When you receive a reconsideration notice, it will outline your right to request an LEP review. Either you or an authorized representative can file the appeal. The reconsideration form also lists examples of situations that may qualify for review.

Important: If a beneficiary receives Extra Help (Low-Income Subsidy), they do not have to pay the Late Enrollment Penalty at all.

Watch a YouTube video on the drug cap, please note; CMS adjusts the drug cap amount annually.

How to File an LEP Appeal

To request a reconsideration, you must complete the Part D LEP Reconsideration Request Form (C2C) and submit it through one of the following methods:

By mail:

• Standard mail – C2C Innovative Solutions, Inc.
  Part D LEP Reconsiderations
  P.O. Box 44165
  Jacksonville, FL 32231-4165
• Courier/tracked mail – C2C Innovative Solutions, Inc.
  Part D LEP Reconsiderations
  301 W. Bay St., Suite 600
  Jacksonville, FL 32202

By fax:

• 833-946-1912

Online submission (fastest option):

• Visit C2C Innovative Solutions to create an account and securely upload the completed form.

If someone such as a family member, doctor, or agent files the request on your behalf, they must be designated as your representative by completing the final section of the reconsideration form.

The Appeal Review Process

• LEP appeals are reviewed by an Independent Review Entity (IRE) contracted by Medicare.
• The IRE will notify you of their decision within 90 days of receiving your request.
• The outcome may include upholding the penalty, overturning it, or dismissing the request.

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Key Takeaways

• Missing Part D enrollment without creditable coverage for more than 63 days can lead to an LEP.
• Beneficiaries have the right to appeal the penalty through a reconsideration request.
• Appeals can be filed by mail, fax, or online with C2C Innovative Solutions.
• Those who qualify for Extra Help never have to pay the LEP.

Understanding the appeals process helps beneficiaries avoid unnecessary costs and ensures fair review of their coverage history.

Agents: Educating clients about timely Part D enrollment and LEP appeals is an important way to protect them from unexpected penalties—and to strengthen your role as a trusted Medicare advisor.

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SEPs for Medicare Part B Enrollment

For Medicare beneficiaries, the timing of enrollment is very important. While most people enroll in Medicare Part B during their Initial Enrollment Period (IEP) when they first become eligible, life circumstances don’t always fit neatly into those timelines. That’s where SEPs for Medicare Part B enrollment come in.

SEPs provide and opportunity for beneficiaries to sign up for Part B outside of their IEP or the GEP(General Enrollment Period), without facing late enrollment penalties, provided they meet certain conditions.

What is Medicare Part B

Medicare Part B helps cover outpatient care, doctor visits, preventive services, lab work, durable medical equipment, and more. Since it comes with a monthly premium, some people delay enrolling—especially if they’re still working and covered under an employer health plan.

When Can You Qualify for a Part B SEP

SEPs are designed to protect people who already had other coverage or experienced specific life events. Some of the most common situations include:

1. Employer or Union Coverage

• If you (or your spouse) are still working past 65 and covered by a group health plan, you can delay enrolling in Part B.
• Once that employment ends, or the employer coverage ends; you qualify for an 8-month SEP to sign up for Part B without penalty.

2. Coverage Through a Spouse

• If you’re covered under your spouse’s employer plan, the same SEP protections apply.
• This is important for individuals who retire before their spouse does, or vice versa.

3. Losing Other Creditable Coverage

• If you lose health insurance that’s considered “creditable” by Medicare standards (meaning coverage that’s at least as good as Medicare), you’ll likely qualify for an SEP.

Watch a YouTube video on Medicare enrollment periods

4. Special Circumstances (New Rules Starting in 2023)

CMS expanded SEPs to include situations such as:

• Emergency or disaster situations (declared by FEMA or other agencies).
• Employer or plan error where you were misinformed about enrollment.
• Medicaid coverage ending.
• Other exceptional conditions as determined by Medicare.

Forms you’ll need for a PArt B SEP enrollment

When enrolling in Medicare Part B during a Special Enrollment Period, most beneficiaries will need to complete two key forms:

• CMS-40B — Application for Enrollment in Medicare Part B (Medical Insurance); this is the standard enrollment form used to request Part B coverage. The beneficiary must complete this form.
• CMS-L564 — Request for Employment Information; this is the standard enrollment form beneficiaries use to request Part B coverage. It is completed by the beneficiary and their employer to verify that you had group coverage based on employment. Medicare uses it to confirm penalty free eligibility.

Please note: If your employer cannot fill out the CMS-L564, you can still submit it along with other proof of creditable coverage, such as pay stubs showing insurance deductions or health plan ID cards.

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Why SEPs Matter

Missing your enrollment period for Part B can lead to late enrollment penalties that increase your premium by 10% for each 12-month period you could have had Part B but didn’t enroll. These penalties usually last for as long as you have Medicare.

SEPs help people avoid those lifelong penalties if they had valid reasons for delaying enrollment.

Key Takeaways for Beneficiaries and Agents

• Always confirm whether an employer plan is considered creditable coverage before delaying Part B.
• Keep records of your health coverage and employment dates; Medicare often requires documentation.
• Complete both CMS-40B and CMS-L564 when applying for a Part B SEP.
• Educate clients that timing is everything. Even with an SEP, strict deadlines apply.

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Special Enrollment Periods give Medicare beneficiaries flexibility and protection when life events affect their coverage. Knowing the rules and having the right forms ready can save money, prevent penalties, and ensure continuous access to healthcare.

What Value Based Care Means

Healthcare has been shifting away from the “fee-for-service” model, and Medicare is at the center of that transformation. Traditionally, doctors and hospitals were paid based on the number of tests, procedures, or visits they provided, regardless of whether patients got healthier. What Value Based Care means is a little different. VBC rewards providers for improving patient health and keeping costs down.

The Basics of Value Based Care

Value Based Care is about quality over quantity. Instead of simply paying for services rendered, Medicare ties payments to outcomes such as:

• Better health results – like reduced hospital readmissions or better management of chronic diseases.
• Improved patient experience – including communication, accessibility, and overall satisfaction.
• Lower overall costs – through preventive care, care coordination, and reduced unnecessary treatments.

How Medicare Uses Value-Based Care

Medicare has introduced several programs and models to encourage providers to embrace VBC. Some of the key examples include:

• Accountable Care Organizations (ACOs): Groups of doctors, hospitals, and other providers who work together to give coordinated, high-quality care to Medicare patients. If they save money while meeting quality goals, they share in those savings.
• Bundled Payments for Care Improvement (BPCI): Instead of billing separately for every service, providers receive a single payment for an entire episode of care, like a hip replacement or heart surgery.
• Hospital Readmissions Reduction Program (HRRP): Hospitals receive rewards for keeping patients healthier after discharge and avoiding costly readmissions.
• Medicare Advantage Plans (MA): Many MA plans already use value-based arrangements with providers to improve preventive care and manage chronic conditions.

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Why Value-Based Care Matters

For Medicare beneficiaries, Value-Based Care means:

• More preventive services: Encouragement to get screenings, vaccines, and wellness visits.
• Better coordinated care: Doctors and specialists share information to avoid duplication and gaps.
• Healthier outcomes: The focus is on managing conditions and preventing complications, not just treating problems when they arise.

For the healthcare system overall, VBC helps reduce wasteful spending and ensures taxpayer dollars are used more effectively.

Watch a YouTube video on SEP changes for Dual, Partial Dual & LIS members

The Future of Value-Based Care

Medicare’s long-term goal is to have most of its payments tied to value instead of volume. This means more providers will be incentivized to deliver patient-centered care that is proactive, efficient, and focused on health rather than procedures.

Value-Based Care is Medicare’s way of rewarding healthcare providers for keeping patients healthier, not just for doing more. As this model continues to grow, beneficiaries can expect better care coordination, more preventive services, and a stronger focus on long-term health.

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ACA Changes for Plan Year 2026 – What This Means for Enrollees

Premium Increases Looming Large

In this post, we will go over some of the ACA changes for plan year 2026. The first one being; a median premium increase. Nationwide across ACA Marketplace plans, insurers have proposed median premium increases of around 18–20% for 2026; about double the rate change seen in 2025.

Enhanced Tax Subsidies Expire

The enhanced premium tax credits, a key feature under the American Rescue Plan and later extensions, could expire at the end of 2025, unless Congress acts. Their expiration may trigger both premium and enrollment shifts:

Over 75% increase in net premiums for many enrollees. Gross premiums also projected to climb, due to a less healthy remaining risk pool as healthier individuals opt out

Enrollment Process & Verification Tightened

Several regulatory changes taking effect in 2025 will reshape how people enroll in 2026 plans:

• Maximum out-of-pocket limits will rise: individual limit is $10,600 for 2026 and $21,200 for families.
• $5 monthly premium for auto-renewed $0 premium plans, unless eligibility is actively reconfirmed
• Auto-renewal from Bronze to Silver (for CSR-eligible individuals) is no longer allowed; this could lead to missed subsidies without active action
• SEP (Special Enrollment Period) applicants now face pre-enrollment eligibility verification in HealthCare.gov states—covering at least 75% of new enrollments; changes are temporary for 2026
• Monthly enrollment windows for low-income people, introduced under Biden, will be discontinued, and the open enrollment period will be shortened by a month

Watch a YouTube video on ACA contracting for agents and agencies

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HSA Eligibility Expanded

• Starting in 2026, Bronze and Catastrophic Marketplace plans become HSA-eligible, high-deductible health plans (HDHPs). Additionally, direct primary care (DPC) membership won’t disqualify HSA contributions, and DPC fees become qualified medical expenses
• This provides greater tax-advantaged savings options and can help lower Modified Adjusted Gross Income (MAGI) to potentially retain subsidy eligibility

“One Big Beautiful Bill Act” & Medicaid Cuts

• The sweeping One Big Beautiful Bill Act (H.R.1) introduces:
  • $1.2 trillion in cuts to Medicaid and ACA subsidies, paired with stricter eligibility and verification requirements
  • Medicaid work requirements (80 hours per month), more frequent eligibility checks, reduced provider taxes, and limits on Medicaid for green card holders and immigrants
  • The CBO estimates up to 10 million will lose Medicaid, 2 million ACA coverage, and others become uninsured
  • The legislation also includes expansions like a Rural Hospital Fund, but critics say many will face access barriers

Reduction of Gender-Affirming Care & Legal Challenges

• The Trump administration’s proposed rule would remove gender-affirming care as an essential health benefit for ACA plans starting in 2026
• Other rules allowing insurers to deny new coverage if past premiums are unpaid, stricter income verification, and other barriers may cause 725,000 to 1.8 million people to lose coverage
• Mayors and doctor groups are suing, arguing these changes undermine ACA’s purpose; litigation is ongoing

Summary Table: What 2026 Holds for ACA

The 2026 ACA landscape is shifting dramatically. With rising costs, tighter eligibility, and policy rollbacks, coverage is becoming more complex and costly for many Americans. While expanded HSA access and some protections (like the Rural Hospital Fund) offer benefits, they don’t offset affordability challenges.

Agents, stay up-to-date on the our latest webinars an agent events.

For consumers:

• Actively confirm eligibility during open enrollment—not auto-renew.
• Explore HSA-compatible options (like Bronze plans) to reduce taxable income and manage costs.
• Keep an eye on subsidy extensions; Congressional action could mitigate higher premiums.

For policymakers and advocates:

• Continuing subsidies and preserving access remain critical to maintaining ACA’s promise.
• Legal and policy responses to rollback rules (e.g., gender-affirming exclusions) could reshape outcomes before 2026.

The Value of Cancer Insurance – Why Medicare Agents Should Offer It

When working with Medicare clients, it’s easy to focus on the basics; Original Medicare, Medicare Advantage, Part D, and Medigap plans. However, one area that often gets overlooked is cancer insurance. The value of cancer insurance is something that should not be overlooked. This type of supplemental coverage can be a valuable addition to a client’s overall healthcare strategy, offering peace of mind and financial protection when it’s needed most.

Why Cancer Insurance Matters for Medicare Clients

While Medicare provides solid coverage for hospital stays, doctor visits, and treatments, it does not cover all of the costs associated with a cancer diagnosis. Beneficiaries may face:

• High out-of-pocket costs for chemotherapy, radiation, or specialty medications.
• Prescription drug expenses, especially for oral cancer drugs under Part D.
• Costs outside of Medicare coverage, such as lodging, transportation, and home assistance.

Cancer insurance offers clients a lump-sum benefit or scheduled payments that they can use however they choose; whether for medical bills, experimental treatments, or everyday living costs.

The Benefits for Medicare Clients

1. Financial Protection: Cancer treatments can be lengthy and expensive. A supplemental policy can help fill gaps and reduce financial stress.
2. Flexibility: Benefits are often paid directly to the policyholder, so they decide how to use the funds.
3. Peace of Mind: Clients know they have extra support if faced with a cancer diagnosis.
4. Complements Medicare: Even with a Medigap or Medicare Advantage plan, out-of-pocket costs can add up quickly.

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Beyond Medical Bills: Everyday Expenses Cancer Insurance Can Help Cover

One of the biggest advantages of cancer insurance is that it isn’t restricted to healthcare bills. Many policies allow beneficiaries to use the funds however they need. This flexibility can help cover:

• Travel expenses to and from treatment centers.
• Lodging and meals if treatment requires staying overnight away from home.
• Lost income if the policyholder or a spouse reduces work hours to accommodate treatments.
• Childcare or caregiver costs for clients who need extra support at home.
• Home modifications (ramps, stair lifts, etc.) if mobility becomes an issue during treatment.
• Everyday bills like utilities, rent, groceries, or car payments, so clients don’t fall behind financially while focusing on recovery.

These are real-world expenses that traditional health insurance, including Medicare, does not cover, but cancer insurance can help pay for.

Why Agents Should Offer Cancer Insurance

For agents, cancer insurance is more than just an add-on product; it’s an opportunity to:

• Protect your clients’ financial wellbeing by addressing a risk area that Medicare alone doesn’t fully cover.
• Build stronger client relationships by showing you’re thinking beyond the basics.
• Diversify your portfolio and increase cross-selling opportunities with products that provide real value.
• Differentiate yourself from other agents by offering a more comprehensive healthcare strategy.

Take a look at our YouTube video on why and how to sell ancillary with Medicare in 5 mins

Riders That Can Enhance Cancer Insurance

Many carriers offer optional riders that make cancer insurance even more customizable. Some examples include:

• Heart Attack & Stroke Rider: Expands coverage to other major health events.
• Return of Premium Rider: Refunds premiums if the client never files a claim.
• Wellness Rider: Pays a small benefit for completing preventive screenings (mammograms, colonoscopies, etc.).
• Intensive Care Rider: Provides additional benefits for ICU stays.
• Hospital Confinement Rider: Offers daily benefits for hospital stays, helping offset non-covered costs.

The Bottom Line

Cancer insurance may not be top-of-mind for your clients, but it should be. With the rising cost of treatment and the financial gaps left by Medicare, this coverage can make all the difference. Not only can it help cover medical expenses, but it also provides funds for everyday living costs that traditional health insurance never touches.

For agents, offering cancer insurance, especially with customizable riders, means providing a higher level of service, protecting clients’ financial futures, and strengthening your business.

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

Helping your clients prepare for the unexpected is one of the most valuable things you can do. Adding cancer insurance to your portfolio ensures you’re offering them the complete protection they deserve.

Medicare Coverage of Hospice Care

Facing a serious illness can be overwhelming, but hospice care helps provide comfort, dignity, and support for beneficiaries and their families during end-of-life care. One of the most common questions people ask is about Medicare coverage of hospice services. We will go over the different types Medicare plans and how they cover hospice.

Hospice Coverage Under Original Medicare (Parts A & B)

Medicare Part A covers hospice for beneficiaries who:

• Have a terminal illness with a life expectancy of 6 months or less, as certified by a doctor.
• Choose comfort-focused treatment instead of curative treatment.
• Elect hospice care through a Medicare-approved hospice provider.

What Part A covers:

• Doctor and nursing services
• Medications related to pain relief and symptom management
• Medical equipment and supplies (wheelchairs, walkers, oxygen, bandages, etc.)
• Physical, occupational, and speech therapy when needed for comfort
• Social worker and counseling services
• Short-term inpatient or respite care

Costs under Original Medicare:

• $0 for hospice care itself
• A small copay (up to $5) for each prescription related to pain/symptom management
• 5% of the Medicare-approved amount for inpatient respite care

Hospice Coverage Under Medicare Advantage (Part C)

Even if you’re enrolled in a Medicare Advantage (MA) plan, hospice benefits are still provided directly by Original Medicare, not the MA plan.

Here’s how it works:

• You continue to be a Medicare Advantage member, but hospice services are billed through Medicare Part A.
• Your MA plan may still cover other non-hospice services (like supplemental benefits, prescription drugs, and other medical care unrelated to your terminal illness).
• You should confirm with your hospice provider and MA plan how coverage will coordinate for services not related to your hospice care.

Hospice and Medicare Supplement (Medigap)

If you have a Medicare Supplement (Medigap) policy along with Original Medicare:

• Your hospice care costs are already minimal under Part A.
• A Medigap plan may help cover other related costs, such as Part A coinsurance or costs for services outside the hospice benefit.
• Medigap coverage varies by plan, although policies help reduce out-of-pocket expenses for services you may still need while receiving hospice care.

Learn how Advanced Diabetes Supply can help clients get needed diabetic supplies

Key Takeaways

• Original Medicare covers hospice care under Part A with very little out-of-pocket cost.
• Medicare Advantage members receive hospice care through Original Medicare, while their MA plan may still cover other unrelated health needs.
• Medicare Supplements work alongside Original Medicare to reduce additional out-of-pocket costs, but hospice itself is already well-covered.

Hospice is one of Medicare’s most comprehensive benefits, ensuring comfort, support, and dignity in a person’s final months. Whether you’re on Original Medicare, a Medicare Advantage plan, or have a Medigap policy, Medicare provides hospice coverage when it’s needed most.

Agents:

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Understanding Medicare’s SSBCI Benefits: What They Are and Who They Help

If you’re a Medicare beneficiary or a Medicare agent working with clients you may have come across the term SSBCI. It stands for Special Supplemental Benefits for the Chronically Ill; it’s part of Medicare Advantage plans (not Original Medicare). Understanding Medicare SSBCI benefits is important. These benefits are designed to help people with certain chronic health conditions live healthier, more independent lives by addressing needs that traditional Medicare doesn’t usually cover.

Let’s break down what SSBCI is, how it works, and why it’s so important.

What Are SSBCI Benefits

SSBCIs allow Medicare Advantage plans to offer non-medical supportive benefits to enrollees with serious chronic illnesses. These can include things like:

• Preloaded grocery or utility cards
• Home modifications (e.g., grab bars, ramps)
• Air purifiers or pest control
• Meal delivery
• Social or physical activity programs

The benefits come with an important rule: each benefit must show a reasonable expectation of improving, or at least maintaining, the enrollees’ health or functional status. These targeted benefits can help prevent hospital visits and keep members healthier at home.

Who Qualifies for SSBCI Benefits

To be eligible, an enrollee must meet a three-part definition of “chronically ill,” including:

1. Having one or more complex or serious chronic conditions
2. Being at high risk of hospitalization or adverse outcomes
3. Needing intensive care coordination

Eligibility standards align with what qualifies for Chronic Condition Special Needs Plans (C-SNPs), though not all plans offer SSBCIs.

How SSBCI Differs From “Regular” Medicare Advantage Benefits

Most Medicare Advantage benefits are “primarily health-related.” SSBCI benefits expand that definition to include supports that aren’t strictly medical, as long as they address a specific health condition and can reasonably be expected to improve or maintain health.

Although regular supplemental benefits might include gym memberships or dental coverage for everyone in the plan, SSBCI benefits are customized to the needs of individuals who meet specific health criteria.

Why SSBCI Benefits Matter

Holistic Support: SSBCIs target real-life challenges; nutrition, safety, social connection, that can worsen health.

Flexibility: They can be customized to meet local needs and conditions.

Preventive Benefit: Reducing real-world barriers may lower healthcare costs down the line.

Personalized Care: Plans determine how SSBCIs are structured, shaping the benefits based on member needs.

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What’s New in 2026

Stricter Rules on What Plans Can’t Offer

Starting in 2026, Medicare Advantage plans will face a tightened definition of SSBCI. CMS has codified a list of non-allowable benefits, meaning some popular extras are now prohibited under SSBCI, including:

• Junk food, unhealthy groceries
• Alcohol, tobacco, or cannabis-related items
• Life insurance or funeral benefits
• Cosmetic procedures not covered by Original Medicare
• Insurance discounts unrelated to health care
• Hospital indemnity or unrelated insurance products

Mandatory Mid-Year Notifications

Also beginning in 2026, MAOs (Medicare Advantage Organizations) must send personalized mid-year notices (between June 30 and July 31) to members who have unused supplemental benefit allowances. These notices must include:

• Which benefits the enrollee hasn’t used (from Jan 1–Jun 30)
• Eligibility criteria and limitations
• Instructions on how to access the benefits and provider networks

This ensures beneficiaries don’t miss out on benefits they’re entitled to because they weren’t aware of them.

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Other Medicare-Wide 2026 Changes (Broader Context)

While not SSBCI-specific, here are some broader 2026 updates that complement the Medicare Advantage landscape:

• Automatic Renewal of the Medicare Prescription Payment Plan (MPPP); opt-outs must be processed within three days
• Part D Out-of-Pocket Cap increasing to $2,100 (up $100 from 2025)
• Part D Deductible capped at $615 (up by $25)
• Insulin Cost Cap: Still $35 or less, whichever is lower of negotiated or maximum fair price—now effectively enforced annually
• Adult Vaccines under Part D remain free with no cost-sharing as a permanent policy

Bottom Line

SSBCIs remain a powerful innovation within Medicare Advantage pushing beyond clinical coverage to tackle the lived experiences of chronically ill beneficiaries. But in 2026, plans must tighten the focus and communicate more clearly, including:

• No more non-health-related extras under SSBCI
• Required mid-year check-ins to help enrollees use their benefits effectively

Those who rely on SSBCIs, should:

Always review your 2026 ANOC for SSBCI benefit changes. Pay close attention to mid-year notices and unused benefits. Contact a licensed Medicare agent if you have questions about your current coverage or to look at your options during AEP or other available enrollment periods.

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