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Common Medicare Enrollment Mistakes (and How to Avoid Them)

Enrolling in Medicare is one of the most important steps many of us take when we transition into retirement or experience a qualifying medical condition. But with multiple parts, deadlines, and plan types, it’s easy to make costly mistakes that could lead to penalties, gaps in coverage, or higher out-of-pocket expenses. We have listed some common Medicare Enrollment mistakes below with the hope that your clients can avoid them.

Missing the Initial Enrollment Period (IEP)

The Mistake: Waiting too long to enroll in Medicare Parts A and B can lead to late enrollment penalties, some of which are permanent.

How to Avoid It:
You’re eligible to enroll during a 7-month window:

• Starts 3 months before your 65th birthday month
• Includes your birthday month
• Ends 3 months after

If you’re not working or don’t have credible employer coverage, enroll during your IEP to avoid penalties.

Not Enrolling in Part B on Time

The Mistake: Some people mistakenly delay enrolling in Medicare Part B (medical insurance), thinking they don’t need it — even when they don’t have other credible coverage.

The Penalty: A 10% increase in premiums for every 12-month period you were eligible but didn’t enroll. This penalty lasts as long as the beneficiary has Part B coverage (for life).

How to Avoid It:
If you’re not actively working and don’t have employer-sponsored coverage, you should enroll in Part B when you’re first eligible. COBRA, retiree coverage, and the Marketplace do not count as credible coverage for Part B delays.

Not Enrolling in Part D (Drug Coverage)

The Mistake: Delaying enrollment in a Part D drug plan, thinking you don’t need one because you don’t take medications.

The Penalty: A permanent late enrollment penalty added to your Part D premium.

How to Avoid It:
Even if you don’t take prescriptions now, it’s wise to enroll in a low-cost Part D plan when you’re first eligible. You’ll avoid penalties and have coverage in place when you need it.

Watch a YouTube Video on Medicare Enrollment Periods

Assuming Medicare Covers Everything

The Mistake: Many people think Medicare is free and will cover 100% of their healthcare needs. Unfortunately, that’s not the case.

How to Avoid It:
Learn what Medicare does and doesn’t cover. For example:

• Part A covers hospital care but has a deductible
• Part B covers doctor visits and outpatient care, but only 80% after the deductible
• Medicare doesn’t cover routine dental, vision, hearing aids, or long-term care

Supplemental plans or Medicare Advantage can help fill these gaps.

Not Comparing Plan Options Annually

The Mistake: Sticking with the same plan year after year without reviewing changes.

How to Avoid It:
Use the AEP (Annual Enrollment Period) that runs from Oct 15 – Dec 7 to review:

• Premium changes
• Drug formularies
• Doctor networks
• Copays and out-of-pocket maximums

Plans change annually, and so do your health needs. An annual review ensures you’re in the most cost-effective and appropriate plan.

Relying on Friends or Online Info Without Expert Help

The Mistake: Taking advice from well-meaning friends or reading generic info online without speaking to a licensed agent.

How to Avoid It:
Medicare is personal. Plans vary by location, health needs, income, and prescription use. A licensed Medicare agent can help you compare plans and avoid costly oversights.

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Making the wrong choice with Medicare can cost hundreds, even thousands, over time. Whether you’re helping someone new to Medicare or reviewing your own plan, the smartest thing you can do is work with a licensed Medicare agent who understands the rules, timelines, and local options.

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Medicare for People Under 65: What Benefits and Plans Are Available

When most people think of Medicare, they think of individuals turning 65. But Medicare also covers millions of Americans under age 65 who qualify due to disability or specific medical conditions. Because understanding benefits and plan options is essential to getting the best possible care, we will discuss Medicare for people under 65.

Who Qualifies for Medicare Under Age 65

You may be eligible for Medicare before turning 65 if:

• You’ve been receiving Social Security Disability Insurance (SSDI) for 24 months (consecutive or non-consecutive).
• You have Amyotrophic Lateral Sclerosis (ALS); you automatically get Medicare the same month your SSDI benefits begin.
• You have End-Stage Renal Disease (ESRD); you may qualify for Medicare without waiting 24 months, depending on your treatment and transplant status.

What Medicare Benefits Do You Get

Medicare coverage for those under 65 generally includes:

• Part A (Hospital Insurance): Covers inpatient care, skilled nursing facility care, hospice, and some home health care. Usually premium-free if you worked 40 quarters (or qualify through a spouse).
• Part B (Medical Insurance): Covers doctor visits, outpatient care, preventive services, and durable medical equipment. You pay a monthly premium (standard amount is $174.70/month in 2025, though income can affect this).
• Part D (Prescription Drug Coverage): You can enroll in a standalone drug plan or get drug coverage through a Medicare Advantage plan.

Medicare Advantage (Part C) Plans for People Under 65

Private insurance companies offer Medicare Advantage plans. These plans must cover everything Original Medicare covers and often more, like dental, vision, hearing, gym memberships, and over-the-counter allowances.

Important notes:

• Not every state or county offers Medicare Advantage plans for beneficiaries under 65.
• You must be enrolled in both Part A and Part B to join a Medicare Advantage plan.
• Availability can depend on your ZIP code and health condition.

Some Advantage plans are designed for people with chronic conditions (C-SNPs), which could be a great fit for those with a qualifying illness.

Watch a YouTube video on Chronic Condition MAPD Plans

Medicare Supplement (Medigap) Plans for Individuals Under 65

Medicare Supplement plans (also called Medigap) help pay out-of-pocket costs like deductibles, copays, and coinsurance. They work with Original Medicare (not with Advantage plans).

Here’s the catch:

• Federal law does not require insurance companies to sell Medigap plans to people under 65. But many states do require it.
• If your state allows it, premiums may be higher than for people 65 and older.
• You may not be offered the full range of plans (A–N), and plan availability is very limited and varies widely by state.

Important: Even if you’re under 65 now, you’ll get another Medigap Open Enrollment Period when you turn 65; at that point, you can enroll in any plan with guaranteed issue rights and generally at lower rates.

Prescription Drug Coverage for Under-65 Beneficiaries

If you’re on Original Medicare, you’ll need a standalone Part D plan to cover your medications. These plans vary by region and formulary, so it’s important to review which plan best fits your prescriptions and pharmacy preferences.

If you choose a Medicare Advantage plan with prescription coverage, you don’t need to enroll in a separate Part D plan.

Don’t skip drug coverage! If you delay enrolling in Part D when first eligible and don’t have other credible coverage, you may face a late enrollment penalty later.

Getting Help with Costs: Extra Help & Medicaid

If you’re under 65 and have limited income or resources, you may qualify for:

• Medicare Savings Programs (help pay for Part A and B premiums and other costs)
• Extra Help with prescription drug costs
• State Medicaid programs, which can provide additional services and cost coverage

Medicare for people under 65 can be complex, but it’s also a lifeline. Plan options may differ from those turning 65, especially when it comes to Medigap and Medicare Advantage availability. It’s essential to:

• Review your state-specific rules
• Check if you’re eligible for Extra Help or Medicaid
• Compare Medicare Advantage vs. Original Medicare + Medigap carefully

Remember; coverage options may improve (and become more affordable) when you reach age 65, so be sure to reassess at that time.

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Need help understanding your Medicare options under 65? Contact a licensed Medicare agent who can walk you through what’s available in your area and help you make the most of your benefit.

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Digital Marketing for Medicare Agents: Expand Your Reach Online

The Medicare market is competitive, and while traditional methods like grassroots marketing and referrals still work, today’s successful agents know that digital marketing is key to long-term growth. Whether you’re just getting started or looking to refine your strategy, here are some essential tips for digital marketing for Medicare agents.

Build a Professional Website

Your website is your digital storefront. It should be clean, easy to navigate, and mobile-friendly. Be sure to include:

• A simple explanation of what you do
• Your contact information
• An appointment scheduler or contact form
• Educational content (like blogs or videos)
• Compliance disclaimers (required by CMS)

Tip: Add an FAQ section to answer common Medicare questions; it boosts SEO and builds trust.

Learn about the free website design assistance we offer to our agents.

Start a Blog

Blogging helps you:

• Educate prospects and clients
• Rank higher on Google
• Position yourself as a local Medicare expert

Make your posts easy to read, and include a call to action like “Schedule a Free Medicare Review Today.”

Watch a YouTube video on how to create a successful blog

Use Email Marketing

Email is a low-cost way to:

• Keep in touch with leads and clients
• Share reminders about enrollment periods
• Deliver newsletters or tips

Segment your list (e.g., by age, status, or interest), and personalize your emails with tools like Mailchimp, Constant Contact, or SendGrid.

Always follow CMS guidelines; no marketing AEP-related products before October 1st!

Get Active on Social Media

Platforms like Facebook and LinkedIn are great for reaching seniors and their caregivers. Post regularly and mix up your content:

• Educational posts and videos
• Reminders for enrollment periods
• Client testimonials (with permission)
• “Medicare Tip of the Week”

Join local Facebook groups and community pages; just be careful not to promote directly in restricted groups. Focus on being helpful not on selling.

Use Video to Explain Complex Topics

Short videos are powerful tools. You can create:

• “Explainer” videos for Medicare Parts A, B, C, and D
• Plan comparison walkthroughs
• “Ask Me Anything” Q&A sessions

Use YouTube, Instagram Reels, or Facebook Live. Keep it down to a few minutes and include captions for accessibility.

Set Up a Google Business Profile

A Google Business Profile (formerly Google My Business) helps locals find you when they search “Medicare agent near me.”

Make sure to:

• Keep your hours and contact info updated
• Add photos of your office or events
• Ask clients to leave reviews (and respond professionally)

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Use CRM and Automation Tools

Managing follow-ups is critical. A Customer Relationship Management (CRM) system like Blitz, AgencyBloc or our new addition: the all -in-one agent portal, BOSS (learn more about BOSS) these tolls help:

• Track leads and clients
• Automate birthday or policy renewal reminders
• Manage email campaigns
• Track downline production (for agencies) These last 3 are available with BOSS!
• Book of business reports
• Track your sales

Automation saves time while keeping your outreach personal and consistent.

Track Your Results

Use tools like Google Analytics, Meta Ads Manager, and your email platform to see what’s working and what’s not.

Track:

• Website traffic and page views
• Email open and click rates
• Facebook post engagement
• Number of appointments or contacts per campaign

This data will help you fine-tune your digital marketing strategy over time.

You don’t need to master every digital channel at once. Start small; maybe by building your website and writing one blog post per month. As you get more comfortable, expand into social media or email marketing.

Stay updated on agent events and information

Being present and professional online helps build credibility, reach more prospects, and stay top-of-mind with current clients. With the right tools and strategy, digital marketing can become one of your most powerful Medicare sales tools.

The Canadian Medstore: An Option for Affordable Prescription Drugs

With rising prescription drug costs in the U.S., many Medicare beneficiaries are looking for more affordable options to manage their health. One of the most talked-about resources is The Canadian Medstore. What is the Canadian Medstore; a service that offers access to prescription medications from licensed international pharmacies, often at a significantly lower cost than U.S. retail prices.

But is it safe? Is it legal? And how can seniors take advantage of this option if their Medicare plan doesn’t cover certain drugs or the out-of-pocket costs are too high? Let’s break it down.

What Is The Canadian MedStore

The Canadian MedStore is a licensed prescription referral service that connects U.S. patients with international pharmacies and licensed Canadian sources. It provides a safe and cost-effective alternative for Americans facing high out-of-pocket costs for prescription drugs.

While based in Canada, the service also works with accredited pharmacies in the UK, Australia, and New Zealand, depending on medication availability and pricing.

Watch a quick YouTube video on the Canadian Medstore

How It Works

1. Individuals Supply: Name and date of birth, drug allergies, current medications.
2. Prescription Required: Like any legitimate pharmacy, a valid prescription from a U.S. doctor is required. Just upload, transfer, fax or email them.
3. Medication Match: The Medstore checks availability and pricing from international sources and fulfills the order through the most cost-effective and compliant channel.
4. Shipping to the U.S.: Medications are typically shipped directly to the patient’s home, with delivery times ranging from 2 to 4 weeks.

Is It Legal

Importing prescription drugs for personal use from outside the U.S. is technically not FDA-approved, but the FDA has long used enforcement discretion in cases involving personal importation of medications that:

• Are not controlled substances,
• Are for personal use (usually 90-day supply or less),
• Are not considered high-risk, and
• Are accompanied by a valid prescription.

This makes The Canadian MedStore a viable option for many seniors, especially for maintenance medications or drugs not covered on a Medicare Part D formulary.

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Who Uses It

• Medicare beneficiaries in the coverage gap or with expensive specialty drugs not covered by their plan.
• Patients with chronic conditions like asthma, diabetes, or high cholesterol who need ongoing medications.
• Retirees on fixed incomes trying to stretch their healthcare dollars without compromising quality.

Cost Savings Example

A common brand-name cholesterol drug that costs $500/month in the U.S. might cost as little as $100/month through The Canadian MedStore without sacrificing authenticity or safety.

Pros and Cons

Pros:

• Substantial savings on brand-name medications
• Licensed pharmacists review each order
• Personalized support and prescription management
• Offers automatic refills and mail-order convenience

Cons:

• Not for acute, emergency, or temperature-sensitive medications
• Slower shipping times (2–4 weeks)
• Not all medications are available
• Medicare Part D does not reimburse for these purchases

Considerations for Medicare Beneficiaries

While using The Canadian MedStore can be a great option for those in the Medicare dealing with high costs or formulary exclusions, keep in mind:

• Medicare won’t count these purchases toward your True Out-of-Pocket (TrOOP) costs.
• Individuals cannot submit these drugs for reimbursement under Medicare Part D.
• You should consult with your physician and pharmacist to ensure that the drugs are the correct formulation and dosage.

For Medicare beneficiaries struggling with the cost of prescription medications, The Canadian MedStore can be a helpful lifeline. While not a substitute for comprehensive drug coverage, it can offer peace of mind and price relief for those who would otherwise go without their medications.

If you’re an agent, understanding how services like The Canadian MedStore work can help you better support clients who need alternatives beyond their plan’s coverage. This is another way to maintain your book of business. Always encourage clients to check with their doctor and review all options carefully. Agents; if you would like more information on this service, please contact our office at 203-796-5403. You can also call Pam DiGrigoli at 727-474-3832 and set up an account to offer this service to your clients.

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Understanding SEPs for Medicare Chronic Special Needs Plans (C-SNPs)

Medicare Advantage Special Needs Plans (SNPs) provide targeted care and coordinated benefits to specific groups of beneficiaries. One common type of SNP is the Chronic Condition Special Needs Plan (C-SNP), which is available to individuals diagnosed with specific chronic health conditions. For agents, understanding C-SNP SEPs can ensure your clients receive the best coverage for the care they need.

To help eligible beneficiaries enroll in these plans, Medicare offers Special Enrollment Periods (SEPs) that allow people to join or switch into a C-SNP outside the standard Annual Enrollment Period (AEP).

Let’s explore what C-SNPs are, who qualifies, and how SEPs work to ensure timely access to care.

What is a Chronic Special Needs Plan (C-SNP)

A C-SNP is a type of Medicare Advantage plan tailored for people with certain severe or disabling chronic conditions. Private Medicare-approved insurance companies offer these plans. Plans must include the same benefits Medicare Part A and B provide, and usually include Part D prescription drug coverage.

C-SNPs often provide:

• A care team specializing in the chronic condition
• Coordinated services to help manage the enrollee’s health
• Lower costs on services that relate to the specific condition

Examples of eligible chronic conditions for C-SNPs include:

• Diabetes
• Congestive Heart Failure (CHF)
• Chronic Obstructive Pulmonary Disease (COPD)
• Cardiovascular Disease
• End-Stage Renal Disease (ESRD)

*Note: Medicare rules around ESRD and plan access changed in 2021; people with ESRD can now enroll in most Medicare Advantage plans, but ESRD-specific SNPs still exist in many regions.

Special Enrollment Period (SEP) for C-SNPs

Medicare offers a Special Enrollment Period when an individual is newly diagnosed with a qualifying chronic condition. This allows them to join a C-SNP as soon as they are eligible.

When Does the SEP Apply

You can enroll in a C-SNP:

When you are first diagnosed with a qualifying chronic condition
If you already have a qualifying condition but have not enrolled in a C-SNP before
If you move into or out of a service area that offers your C-SNP
If you lose your C-SNP eligibility because you no longer meet the chronic condition criteria

This SEP allows a one-time enrollment into a C-SNP for each qualifying diagnosis.

How the C-SNP SEP Works

Once diagnosed with a qualifying condition, beneficiaries typically have a Special Enrollment Period that lasts for 3 months, beginning:

• The month they’re diagnosed, or
• The month they are notified of the diagnosis

During this SEP, you can:

• Enroll in a new C-SNP specific to the condition
• Switch from another Medicare Advantage plan or Original Medicare into a C-SNP

Documentation Required

Enrollment into a C-SNP requires proof of the chronic condition, usually in the form of:

• A doctor’s attestation
• Medical records or diagnosis documentation
• A form provided by the plan for the provider to complete

What if Your Condition Improves

If you no longer have the qualifying condition (for example, your doctor no longer considers your diabetes as chronic or disabling), you may be disenrolled from the C-SNP. In that case, you’ll qualify for another SEP to enroll in a different Medicare Advantage plan or return to Original Medicare.

Why Agents Need to Understand C-SNP SEPs

If you’re a Medicare agent, being well-versed in the rules around C-SNPs and SEPs help:

• Connect chronically ill clients with better care coordination
• Avoid unnecessary wait times for clients who need immediate support
• Assist clients with navigating documentation and eligibility

Remember, not all areas offer C-SNPs, so always check plan availability by ZIP code.

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Special Enrollment Periods for Chronic Special Needs Plans offer a vital lifeline to beneficiaries who need enhanced care and support for their chronic conditions. Understanding how and when these SEPs apply ensures that eligible individuals don’t miss out on essential benefits tailored to their health needs.

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Medicare Advantage Enrollment: When and How to Join a Plan

Medicare Advantage (also known as Medicare Part C) is a popular alternative to Original Medicare, offering coverage through private insurance companies approved by CMS. These plans often include additional benefits like dental, vision, hearing, and prescription drugs. For anyone considering Medicare Advantage enrollment, it’s essential to understand the different enrollment periods and special situations that may qualify you for coverage; including the Medicare Advantage Trial Right.

Enroll in Medicare Advantage

There are a few windows when beneficiaries can sign up for a Medicare Advantage plan:

1. Initial Enrollment Period (IEP)

When an individual first becomes eligible for Medicare, they have a 7-month window to enroll:

• Begins 3 months before the month they turn 65
• Includes their birthday month
• Ends 3 months after their birthday month

When an individual qualifies for Medicare due to a disability, their IEP will begin three months before the 25th month of disability benefits and end three months after that month.

2. Annual Enrollment Period (AEP): October 15 – December 7

During AEP, anyone with Medicare can:

• Join a Medicare Advantage Plan
• Switch from one plan to another
• Drop their Medicare Advantage Plan and return to Original Medicare

Changes made during AEP take effect on January 1 of the following year.

Watch a YouTube Video on Medicare AEP Marketing Rules

3. Medicare Advantage Open Enrollment Period (MA OEP): January 1 – March 31

This period is for individuals who are already enrolled in a Medicare Advantage Plan. During MA OEP, you can:

• Switch to a different Medicare Advantage Plan
• Drop your plan and return to Original Medicare (with or without a Part D plan)

Click here to learn more about MA OEP

Special Enrollment Periods (SEPs)

Life happens and Medicare understands that. That’s why certain life events qualify beneficiaries for a Special Enrollment Period (SEP), allowing you to make changes outside the usual windows.

You may qualify for an SEP if:

• You move to a new address that isn’t in your plan’s service area
• You lose other coverage, such as employer, union, or Medicaid coverage
• Your plan is no longer available
• You get coverage through Medicaid or a State Pharmaceutical Assistance Program (SPAP)
• You’re diagnosed with certain conditions, allowing you to enroll in a Special Needs Plan (SNP)
• You’re released from incarceration
• You live in, move into, or move out of a nursing home or other long-term care facility

Each SEP has its own rules and timeframe, typically lasting 2 to 3 months around the qualifying event.

Medicare Advantage Trial Right

The Medicare Advantage Trial Right is a special protection for those trying a Medicare Advantage Plan for the first time. Here’s how it works:

Who Qualifies:

You qualify if:

1. You joined a Medicare Advantage Plan when you were first eligible for Medicare at age 65, and
2. Within the first 12 months, you decide you want to go back to Original Medicare
3. You dropped a Medigap (Medicare Supplement) policy to try a Medicare Advantage Plan for the first time, and within 12 months you want to switch back.

What You Can Do:

• Return to Original Medicare
• Enroll in a Part D prescription drug plan if needed
• In most cases, buy the same Medigap policy you had before, even if the insurance company normally wouldn’t sell it to you

Note: The Trial Right is only available once in your lifetime. It’s designed to offer peace of mind for those unsure whether a Medicare Advantage Plan is the best choice.

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How to Enroll

Enroll in a Medicare Advantage Plan:

• Online at Medicare.gov
• Directly with a carrier – there are a couple ways to do this including: online or over the phone
• Through a licensed Medicare agent or broker, who can help compare options and guide you through the process. This is our favorite option and the service is free!

Be sure to have:

• Your Medicare number
• The effective dates for Parts A and B

Medicare Advantage Plans offer convenience, extra benefits, and sometimes lower costs, but it’s important to choose the plan that fits health needs and lifestyle. Knowing enrollment rights and timing windows helps avoid penalties, gaps in coverage, or being locked out of better options.

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Working While Collecting Social Security

Many Americans choose to continue working while collecting Social Security; whether to stay active, boost income, or ease into retirement. Although those who are not yet at full retirement age, need to understand how working can affect their benefits. The Social Security Administration (SSA) may withhold a portion of their payments if their earnings exceed certain limits.

Can You Work and Collect Social Security

Yes, In fact; you can collect Social Security benefits while working. However, depending on your age and income, benefits may be temporarily reduced.

What Is Full Retirement Age (FRA)

The full retirement age depends on the year an individual was born. For most people retiring today, the FRA ranges from 66 to 67. Earnings limits apply to those who collect Social Security before reaching FRA and continue to work.

2025 Social Security Income Limits & Penalties

In 2025, if an individual is under the full retirement age for the entire year, the SSA deducts $1 from their benefits for every $2 they earn over $22,320/year (approx. $1,860/month).

Example:
Individuals who earn $30,000 while receiving Social Security before FRA are $7,680 over the limit. This means; SSA would withhold $3,840 of their benefits.

For those who reach full retirement age in 2025, the limit is higher:
You can earn up to $59,520 in the months before your birthday, with only $1 withheld for every $3 earned over the limit.

Once you reach full retirement age, there are no penalties; you can work and earn as much as you want without a reduction in benefits.

Learn about Medicare penalties

What Happens to Withheld Benefits

The good news: the money isn’t gone forever. When you reach full retirement age, the SSA will recalculate your benefit amount and increase it to account for the months when benefits were withheld due to excess earnings.

Are There Tax Implications

The answer is; yes, Social Security benefits may be taxable depending on total income (including wages, investments, and other retirement income).

If combined income (defined as adjusted gross income + nontaxable interest + half of your Social Security benefits) is:

• Between $25,000–$34,000 (individual) or $32,000–$44,000 (married), up to 50% of benefits may be taxed.
• Above $34,000 (individual) or $44,000 (married), up to 85% of benefits may be taxable. 

Impact on Medicare premiums

• If you receive Social Security benefits, your Medicare Part B premiums can be automatically deducted from your monthly payment.
• The standard Part B premium for 2025 is $185, but it can be higher based on your income from two years prior. 

Watch a video on OEP, SEPs an Late Part B Enrollment

Other considerations

• You will continue to pay Social Security and Medicare taxes on your earnings while working, regardless of age.
• Working might increase your future Social Security benefits, especially if your current earnings are higher than those in some previous years used to calculate your benefit.
• Some states also tax Social Security benefits. 

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When Working Makes Sense

Even with temporary benefit reductions or taxes, working while collecting Social Security may be worth it. Additional income can help:

• Cover rising expenses
• Delay tapping into savings
• Boost your Social Security by increasing your lifetime earnings record

Key Takeaways

• You can work and collect Social Security
• Earnings limits apply before full retirement age
• Benefits may be withheld, but are recalculated later
• Your benefits may be taxable depending on total income

Before deciding to work while on Social Security, consider speaking with a financial advisor or using the Social Security Earnings Test Calculator at SSA.gov. It’s a smart move to understand how your job may affect your benefits so you can make the most of your income now and in the future.

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Prior Authorization For Original Medicare

Starting January 1, 2026, those on Original Medicare who reside in New Jersey, Ohio, Oklahoma, Texas, Arizona, or Washington, will be required to get a prior authorization for Original Medicare before you receive some covered services. This will cause a major shift in how some beneficiaries use their Medicare benefits.

Medicare is launching a pilot program called the WISeR Model; short for Wasteful and Inappropriate Services Reduction and with it comes something traditionally associated with Medicare Advantage plans: prior authorization.

What Is Prior Authorization

Think of prior authorization as an ok from Medicare. Before your doctor can move forward with certain procedures such as; back surgery, an epidural, or a knee replacement, they have to get Medicare’s approval first. If Medicare doesn’t approve the service, the beneficiary will be on the hook for the entire cost.

This step is designed to prevent beneficiaries undergoing unnecessary or risky treatments, but it also means more paperwork, potential delays, and a new layer of bureaucracy for Original Medicare beneficiaries.

Why Is Medicare Doing This

According to CMS, the WISeR model has three main goals:

• Cutting down on fraud and wasteful spending
• Protecting patients from unnecessary or potentially harmful care
• Using technology and expert review teams to promote high-quality, cost-effective treatment

Medicare emphasizes that the goal is not to deny care, but to ensure the care being provided is truly necessary.

Which Services Will Require Prior Authorization

The WISeR pilot affects 17 outpatient services Medicare has identified as potentially overused or subject to misuse. These include:

• Back and neck surgeries
• Knee and joint surgeries
• Epidural injections and other pain treatments
• Skin grafts
• Nerve stimulators

What You Need to Know if You Have a Medigap Plan

Even if you have a Medicare Supplement plan (Medigap) like Plan G or Plan N, this change still affects you:

Watch a quick video on High Deductible Plan G

• Medicare Must Approve First: Medigap only helps pay your portion after Medicare approves the service. If Medicare denies it, Medigap won’t cover anything.
• Longer Wait Times: Prior authorization can delay access to care while your provider waits for Medicare’s decision.
• Less Flexibility: Traditional Medicare has long been valued for its ease of access to services—this new layer limits that freedom for certain procedures.
• No Formal Appeals: Under the WISeR pilot, there’s no standard appeal process. If denied, your doctor can submit more info, but there’s no official right to appeal like there is in broader Medicare.

How Does This Compare to Medicare Advantage

If this sounds familiar, it’s because Medicare Advantage plans have used prior authorization for years. However, there are key differences:

• Traditional Medicare is administered by the federal government, while Medicare Advantage is offered by private insurers.
• The WISeR model only requires PA for 17 specific outpatient services, while Medicare Advantage may require approval for hundreds of services and medications.

What’s Next

Right now, this is a pilot program affecting just six states. But if it’s successful, Medicare could expand it nationwide or add more services to the list.

Even if you don’t live in one of the six pilot states, it’s wise to stay informed—these changes could affect you in the future.

What Medicare Beneficiaries Should Do

1. Talk to Your Doctor
   Ask if any upcoming procedures might require prior authorization.
2. Plan Ahead
   Build in extra time for possible delays when scheduling certain treatments.
3. Stay Informed
   Keep up with updates from CMS and talk to your Medicare agent, especially if you plan to travel or move to another state.

The WISeR model represents a big change for Traditional Medicare, especially for those who’ve enjoyed its simplicity and flexibility. While the goal is to protect patients and reduce waste, many worry it could delay care or add confusion.

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For now, being proactive is your best defense. Know which services are affected, communicate clearly with your doctor, and keep up with Medicare updates. This pilot could be the first step in a broader transformation of how Original Medicare works.

Medicare Advantage Trial Right Rules: What You Need to Know

For beneficiaries who understand the Medicare Advantage Trial Right Rules, this SEP provides a second chance to find a plan to best fit their needs. Switching health plans is stressful; especially if you’re not sure whether your new Medicare Advantage (MA) plan will meet your needs. Fortunately, Medicare offers a special protection called the Trial Right. This provides MA plan enrollees a one-time opportunity to go back to Original Medicare and Medigap as well as a PDP plan if their MA plan isn’t a good fit.

In this blog, we explain Trial Rights, who qualifies, and how to use it so both Medicare agents and beneficiaries are well informed of all the options.

What is a Medicare Advantage Trial Right

The Trial Right is a federally protected enrollment right under Medicare. It allows certain individuals who try a Medicare Advantage plan for the first time to switch back to Original Medicare. When they switch to Original Medicare, in most cases, purchase a Medigap (Supplement) plan without medical underwriting.

This protection ensures that people aren’t stuck in a plan that doesn’t meet their healthcare needs, especially if they’re new to Medicare or trying out Medicare Advantage for the first time.

When Do Trial Rights Apply

There are the two situations when someone is entitled to a Medicare Advantage Trial Right:

Trial Right #1: First Time Joining a Medicare Advantage Plan

If a beneficiary joined a Medicare Advantage plan for the first time ever (at age 65 or older) and has been enrolled in that plan for less than 12 months, they can:

• Disenroll from the MA plan
• Return to Original Medicare (Part A & B)
• Purchase a Medigap plan (Medicare Supplement) with guaranteed issue rights; no medical underwriting
• Purchase a PDP plan to cover prescription drugs

Example:
Mary turned 65 and enrolled in a Medicare Advantage PPO instead of Original Medicare and Medigap. After 6 months, she realizes she prefers the flexibility of seeing any doctor and wants to switch. She has a trial right to go back to Original Medicare and buy a Medigap plan and PDP plan, even if she now has health issues.

Trial Right #2: Dropping a Medigap Plan to Try an MA Plan

If a beneficiary had a Medigap plan but switched to a Medicare Advantage plan for the first time, and it’s been less than 12 months, they can:

• Drop the MA plan
• Go back to Original Medicare
• Re-enroll in the same Medigap plan (if it’s still available) or buy a similar one from another company; with guaranteed issue rights

Example:
Joe had Plan G for two years, then switched to a Medicare Advantage HMO in January. By September, he misses his Medigap freedom. He can use his trial right to return to Original Medicare and get a Medigap plan without underwriting.

How to Use a Trial Right

Beneficiaries can typically switch during a valid election period such as:

• Annual Election Period (AEP) – Oct 15 to Dec 7
• Medicare Advantage Open Enrollment Period (MA OEP) – Jan 1 to Mar 31
• Special Enrollment Period (SEP) triggered by the trial right

Watch a YouTube video on Medicare OEP, SEPs and LEPs

Once the carrier process the disenrollment:

• Original Medicare (Parts A & B) coverage resumes
• The beneficiary can apply for a Medigap plan with guaranteed issue rights
• Beneficiaries must select Part D (drug coverage) separately, unless already built into the Medigap package

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

Benefits of the Trial Right

• No medical underwriting for Medigap; even if you have pre-existing conditions
• A second chance to choose Original Medicare + Medigap coverage
• Ensures flexibility and peace of mind for new enrollees or first-time MA users

Important Rules and Limitations

• MA Plan enrollees must leave their current MA plan before the 12 months ends.
• It’s a one-time only right; once the beneficiary uses it, they cannot use it again.
• Your Medigap plan must still be available from the insurer, or you can choose another one. You must also apply for a Medigap plan as early as 60 days before the date your MA plan will end or no later than 63 day after your coverage ends.
• The beneficiary must consider prescription drug coverage:
  • If you return to Original Medicare, you’ll likely need to enroll in a standalone Part D plan.
• Not all agents are familiar with this rule; make sure your client knows their rights!

How Agents Can Use This in Sales

• Educate new-to-Medicare clients: They can try MA with confidence knowing they have a Trial Right.
• Use it as a consultative tool; not to push one product over another but to help the client choose what best fits their health and financial needs.
• Document Trial Right eligibility in your CRM or client file; especially if they switch from Medigap to MA.

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

Medicare’s Trial Right protections give beneficiaries peace of mind when trying something new. As an agent, it’s your responsibility to educate clients on their rights and help them make informed decisions if their first choice doesn’t work out.

Helping a client use their Trial Right can be an important opportunity to show your value as a Medicare resource.

The 2026 Final Rule, released by CMS in April 2025, brings meaningful changes to Medicare Advantage (MA), Part D, and Special Needs Plans (SNPs). These updates aim to improve transparency, enhance care for high-needs populations, and modernize how payments are made to insurers. As a Medicare agent, staying informed helps you guide clients accurately and position your sales strategy for success

Key Changes Agents Should Know

1. Medicare Advantage Plan Payment Increase

CMS approved a 5.06% increase in average plan payments for 2026. This is expected to give insurers more room to offer richer benefits, reduce premiums, or expand supplemental services. Once the carriers release the 2026 plan designs, we will see if they have added enhancements.

2. Prescription Drug Reforms (Part D)

• Insulin Copays Capped: $35/month or 25% of the negotiated price; whichever is less.
• Vaccines: ACIP-recommended vaccines remain free (no deductible or cost-sharing).
• Prescription Payment Plan: Beneficiaries can spread out drug cost payments over the year.
  • New guidelines clarify enrollment, pharmacy coordination, and billing practices.

Agents; educate clients on enrolling in the payment plan; especially those with high drug costs.

3. Risk Adjustment Overhaul – Accuracy Takes Priority

CMS is completing its transition to the 2024 CMS-HCC risk adjustment model, which will be 100% in effect for 2026 MA plan payments. This model better reflects today’s healthcare needs by using updated diagnosis groupings and more current data.

Why It Matters:

• Plans with more chronically ill members (diabetes, COPD, heart failure) get higher CMS payments.
• Plans with healthier enrollees receive less.

Impact on Agents:

• Some plans may adjust benefits or premiums in response to expected payment changes.
• You may see enhanced offerings from plans that excel in care coordination and documentation.
• SNPs and plans serving dual-eligibles may experience meaningful shifts; pay attention to service area changes or new plan launches.

Bottom Line: This makes the system more fair, but you should monitor plan benefit designs closely in your key markets

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

4. D-SNP Simplification (Effective 2027)

CMS is improving integration for dual-eligible members with:

• One Medicare-Medicaid ID card
• Unified Health Risk Assessment (HRA)
• Faster HRA and care plan timelines

These changes make D-SNPs easier to explain and more attractive to clients. Prepare now by understanding how your D-SNP partners are adapting.

5. Inpatient Coverage Notification Rules

Plans must now notify both providers and beneficiaries at the same time about inpatient coverage decisions—helping ensure clear, real-time communication during hospital stays.

Watch a quick YouTube video on the Medicare 2026 Final Rule Proposal

6. What Didn’t Make the Cut

CMS did not finalize several proposed changes:

• No Part D coverage for anti-obesity drugs
• No new broker commission rules
• No restrictions on agent marketing or AI guardrails (yet)

Important: CMS has hinted that more agent-related changes may be proposed in the near future. Stay vigilant!

Updated 2026 Agent Commission Rates

CMS has announced significant increases in maximum allowable broker commissions for Medicare Advantage and Part D for Contract Year 2026 representing the largest MA commission bump in years

Click here for all the details

Action Steps for Agents

1. Study how your top plans may adjust benefits due to new risk adjustment payments.
2. Help clients understand the Prescription Payment Plan and insulin savings.
3. Stay tuned for more changes, especially around marketing, commissions, and AI regulations.
4. Start preparing D-SNP marketing materials ahead of the 2027 simplification rollout.

Find out about all the latest events and information for agents

Summary: CMS Final Rule 2026

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.

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

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.