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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.

Agents, stay up-to-date on events and information; click here to learn more.

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

Area	What’s Changing
Premiums	18–20% median hikes proposed; net premiums rising >75% without subsidy extension
Subsidies	Enhanced credits expire – higher costs, fewer covered individuals
Enrollment Rules	Auto-renew changes, $5 premium for $0 plans, without verification/stricter verification
Plan Design	Bronze/Catastrophic become HSA-eligible HDHPs
Medicaid & Budget Cuts	Major federal cuts, work requirements, reduced coverage
Access & Coverage Content	Limits on gender-affirming care, legal challenges underway

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.

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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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Stay up-to-date on the our latest webinars an agent events.

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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Are Copays and Coinsurance Different – Copays vs Coinsurance

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

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

What is a Copay

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

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

What is Coinsurance

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

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

How They Work Together

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

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

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

Why It Matters for Medicare Beneficiaries

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

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

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

Comparison Table

Feature	Copay	Coinsurance
Type	Fixed amount	Percentage of cost
Predictability	Always the same amount	Varies by service cost
When Used	Office visits, prescriptions	Hospital stays, surgery, DME
Example	$25 per doctor visit	20% of procedure cost

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

Lead Sources for Medicare Agents

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

Referrals from Existing Clients

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

Community Events and Educational Seminars

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

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Partnerships with Professionals

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

Online Marketing

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

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

Purchased Leads and Lead Vendor Options

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

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

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

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

Learn more about Medicare Express Leads

See what Lead Star has to offer agents

Local Networking Groups

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

Current Book of Business

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

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

Navigating Medicare Clients with a Power of Attorney

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

Understand the Type of POA in Place

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

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

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

Verify Legal Authority Before Taking Action

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

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

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

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Communicate Clearly and Respectfully

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

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

Document Every Interaction

For your protection and for compliance purposes:

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

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Stay Compliant with CMS and Carrier Guidelines

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

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

The Bottom Line

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

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The Future of Medicare PDPs: Stability and Key Changes

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

Why Stability Matters

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

Key 2026 Changes

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

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What’s at Stake

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

Medicare PDPs: 2025 vs. 2026 at a Glance

Category	2025	2026
Avg. PDP Options	14	Likely similar, low
Benchmark PDPs (LIS)	2	Risk of staying low
Avg. MA-PD Options	34	Stable or growing
Out-of-Pocket Max	$2,000	$2,100
Deductible	$590	$615
Insulin Cap	$35/mo	$35/mo
Vaccine Cost	$0	$0
Payment Plan	Opt-in yearly	Auto re-enroll
Premium Subsidy	$15	$10
Premium Increase Cap	$35	$50
Risk Corridors	Yes	No
Base Premium	$36.78	$38.99
Drug Price Negotiations	No	Yes – 10 drugs
Market Trend	PDPs shrinking	Stability uncertain

Bottom Line

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

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Understanding Your Medicare Plan ANOC: Why it Matters

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

What Is an ANOC

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

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

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

Why Is the ANOC Important

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

By reviewing the ANOC carefully, you can:

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

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What to Do When You Get Your ANOC

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

Bottom Line

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

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