Why Switch from Medicare Supplement Plan F to Plan G
There are some good reasons to switch from Plan F to Plan G. We will compare Medicare supplement Plan F vs Plan G to help illustrate. For years, Medicare Supplement Plan F has been a popular choice for beneficiaries seeking comprehensive coverage. However, recent changes and market trends have led many to consider switching from Plan F to Plan G. While both plans offer great benefits, Plan G provides similar coverage at a lower premium cost.
Key Similarities Between Plan F and Plan G
Both Plan F and Plan G are Medigap plans designed to fill the gaps in Original Medicare (Part A and Part B). Both plans offer comprehensive coverage, including:
- Medicare Part A deductible
- Medicare Part A coinsurance and hospital costs (up to an additional 365 days after Medicare benefits are exhausted)
- Medicare Part B coinsurance or copayments
- Part B excess charges (the amount a provider can charge above Medicare’s approved amount)
- The first three pints of blood
- Skilled nursing facility (SNF) care coinsurance
- Foreign travel emergency coverage (80% up to plan limits)
The only difference is that Plan F covers the Medicare Part B deductible, while Plan G does not.
Why Switch to Plan G
Plan F Is No Longer Available to New Beneficiaries
As of January 1, 2020, Plan F is no longer available to individuals who became eligible for Medicare after that date. This change, part of the Medicare Access and CHIP Reauthorization Act (MACRA), was implemented to reduce overall healthcare costs.
Due to the fact that Plan F is closed to enrollees who turn 65 after Jan, 1, 2020, its risk pool is aging. This can lead to higher premiums over time as the pool becomes more expensive to insure.
Lower Premiums
Plan G often has significantly lower monthly premiums than Plan F does. While Plan G requires beneficiaries to pay the Medicare Part B deductible out-of-pocket ($257 for 2025), the savings in premiums can more than make up for this cost.
For example, if Plan F costs $50 more per month than Plan G, you’d save $600 each year by switching to Plan G. The savings would easily offset the $257 deductible.
Similar Comprehensive Coverage
Aside from the Part B deductible, Plan G provides identical coverage to Plan F. After meeting the deductible, Plan G covers all Medicare-approved expenses just like Plan F does.
Premium Stability
Because Plan G is open to new enrollees, its risk pool is younger and more diverse compared to Plan F. This dynamic helps keep premiums more stable over time.
In contrast, Plan F’s closed risk pool may lead to disproportionately higher premium increases as it’s enrollee population ages.
Making the switch sooner rather than later ensures you can take advantage of Plan G’s cost savings without disruption to your coverage.
Things to consider
Health Underwriting
Beneficiaries outside their initial enrollment period or guaranteed-issue period, may need to go through medical underwriting to switch plans. This means, insurers evaluate health status and may deny coverage or charge higher premiums based on pre-existing conditions.
Evaluate Your Healthcare Needs and budget
All potential enrollees should carefully calculate out-of-pocket costs, including the Part B deductible, to ensure Plan G is a cost-effective choice.
Enlist the help of a licensed agent
Because navigating Medigap plan changes can be complex, a licensed Medicare agent can help compare premiums, evaluate options, and explain the implications of switching plans. Agents can help submit the application to ensure it is done correctly as well as advise clients when to cancel their current coverage.
It is very important to confirm eligibility to enroll in or change plans and be aware if underwriting will apply.
Learn about Medicare enrollment periods – watch a quick YouTube video
More thoughts on Plan G
Switching from Medicare Supplement Plan F to Plan G is a practical choice for many beneficiaries seeking to reduce their healthcare costs without sacrificing coverage. With lower premiums, stable pricing, and nearly identical benefits, Plan G offers exceptional value especially for those who don’t mind paying the Part B deductible.
Those considering the switch should consult a licensed Medicare agent to ensure a seamless transition and take advantage of the savings and benefits Plan G has to offer. Making an informed decision now can lead to significant cost savings and peace of mind in the years to come.
The question; why sell Medicare supplement HDG is easy to answer. As healthcare costs continue to rise, more Medicare beneficiaries are looking for affordable yet comprehensive medical coverage. High Deductible Plan G (HDG) has emerged as an attractive choice, combining the robust benefits of traditional Medicare Supplement Plan G with significantly lower premiums. For insurance agents, promoting HDG can be a win-win offering value to clients while providing a competitive edge in the Medicare market.
Understanding High Deductible Plan G
High Deductible Plan G works in a similar way to standard Plan G. Both plan options cover the same benefits once the beneficiary meets an annual deductible. For 2025, the deductible for HDG is set at $2,870. In other words, beneficiaries pay out-of-pocket for Medicare-covered expenses until they meet this threshold. Once the beneficiary reaches the deductible, the plan covers:
- Medicare Part A coinsurance and hospital costs.
- Medicare Part B coinsurance or copayments.
- The first three pints of blood
- Skilled nursing facility (SNF) care coinsurance.
- Part A hospice care coinsurance/copays.
- Foreign travel emergency coverage (up to plan limits).
The other difference between a standard Plan G and a HDG plan is the premium. HDG premiums are significantly lower than those for standard Plan G, making it an appealing option for cost-conscious beneficiaries.
Why agents should sell HDG
- Appeal to cost-conscious clients: HDG is an excellent solution for beneficiaries who want comprehensive coverage and are willing to pay a higher deductible in exchange for lower monthly premiums. Many retirees on fixed incomes consider this a good option, especially those in good health who do not expect many healthcare expenses.
- Growing market: With healthcare costs on the rise, there is a growing trend toward high-deductible health plans. Educating clients about HDG allows agents to tap into this expanding market of budget-conscious Medicare beneficiaries.
- Competitive edge: Offering HDG plans show the agents ability to provide diverse options tailored to individual financial and healthcare needs. Agents who can explain the cost-benefit analysis of HDG effectively are more likely to earn trust and build long-term client relationships.
- Cross-selling opportunities: Beneficiaries who choose HDG may still need assistance with other healthcare expenses. Agents can use this opportunity to cross-sell ancillary products such as dental, vision, and hearing plans, hospital indemnity or cancer heart attack and stroke coverage.
- Client Retention: The affordability of HDGs are an excellent option for clients who might otherwise drop supplemental coverage due to cost concerns. By proactively offering HDG, agents can retain clients who might otherwise feel Medicare Supplements are unaffordable.
Click here to get some tips to maintain your book of business
How to Sell HDG Effectively
- Be sure you educate potential clients. Clearly explain how HDG works. Be sure to emphasize the trade-off between lower premiums and the higher annual deductible. Use understandable examples to illustrate potential cost savings.
- Explain the flexibility of the plans. Emphasize that HDG offers the same benefits as standard Plan G after the deductible is met. Clients can enjoy peace of mind knowing they’re protected against catastrophic expenses.
- Put the focus on the plan’s affordability. Compare HDG premiums with standard Plan G and other Medicare Supplement plan premiums. Showcase how the premium savings can outweigh the deductible for clients who have minimal healthcare needs.
- Use calculators or other tools to demonstrate potential savings with HDG, tailored to the client’s unique circumstances. This personalized approach can make the benefits of HDG more understandable.
- Be prepared to address common objections, such as concerns about meeting the deductible. Highlight strategies for managing out-of-pocket costs and reassure clients about the plan’s comprehensive benefits.
Watch a quick YouTube video on selling ancillary products
Agents to join our team or existing agents who want to add a product or carrier – click here
A few more things to consider
Medicare Supplement HDG Plans offer a winning combination of affordability and comprehensive coverage, making it a valuable option for many Medicare beneficiaries. For agents, HDG plans provide an opportunity to meet the needs of cost-conscious clients, differentiate themselves in a competitive market, and build lasting client relationships.
By focusing on education, affordability, and personalized service, agents can successfully position HDG plans as a smart choice for Medicare beneficiaries.
The Next 15 Drugs for Medicare Price Negotiations
In a landmark move aimed at reducing prescription drug costs, HHS has announced the new drugs for price negotiations. The list contains 15 drugs. This initiative, part of the Inflation Reduction Act (IRA), represents another step toward making life-saving medications more affordable for millions of Medicare beneficiaries.
What started the Medicare drug price negotiations
In the past, Medicare was prohibited from negotiating drug prices directly with pharmaceutical companies. However, in 2022 the IRA was signed into law and Medicare gained the authority to negotiate prices for some specific high-cost drugs covered by Medicare Part B and Part D. The object of this program is to lower out-of-pocket medication costs for beneficiaries and reduce healthcare spending.
The list of drugs for the second cycle of negotiations:
- Ozempic, Rybelsus, Wegovy
- Trelegy Ellipta
- Xtandi
- Pomalyst
- Ibrance
- Ofev
- Linzess
- Calquence
- Austedo, Austedo XR
- Breo Ellipta
- Tradjenta
- Xifaxan
- Vraylar
- Janumet, Janumet XR
- Otezla
More about the negotiations
The second cycle of the price negotiations allow drug companies with a selected drug until February 28, 2025 to make the decision weather or not to participate. CMS will consider the clinical benefits of the selected drug. It will also take into consideration how it meets medical needs as well as it’s impact on specific populations. CMS also considers the manufacturers’ Costs for research, development, production and distribution.
The first 10 drugs
The first 10 drugs chosen for negotiations were announced by the Dept. of HHS in August 2023. During the first cycle of negotiations, Medicare reached an agreement with the drug manufacturers on all 10 of the drugs. The new lower prices for those drugs is due to go into effect as of January 1, 2026.
The negotiated rates for the first 10 drugs will be between 38 to 79 % less than their current list prices. In 2026, could save Medicare beneficiaries about $1.5 billion in out of pocket costs.
Watch a quick YouTube video on the$2,000 drug cap
Moving forward, CMS plans to choose 15 more drugs in the third cycle of negotiations. After the third cycle, they plan to choose as many as 20 additional drugs for the subsequent cycles.
Take a look at the CMS fact sheet on the drugs chosen for the Drug Price Negotiation Program
Medicare commissions are not as straight forward as we want them to be. Many agents are confused when they receive their commission deposits. That is why reading Medicare Commission Payments Explained may help unravel the mystery. It is important to note: commission payments require a certain amount of attention to detail.
CMS and commissions
Each year the maximum allowable commissions for Medicare Advantage and PDP sales is set by CMS. The amounts vary by state and can usually be found online once they are available. Unfortunately, there are many different situations that determine how much of that commission an agent receives for each sale.
For the last several years, CMS has consistently raised the commission rates. The renewal amount differs from the amount agents receive for an initial enrollment. Renewal commission amounts also change annually and add up to half the amount of the initial enrollment commission rate. The rates are decided by state and each state is put into a group. The state groupings are (CA and NJ), (CT, PA and DC), (Puerto Rico and US Virgin Islands) and all the other states are in the “National” bucket. The highest pay goes to CA and NJ, followed by CT,PA and DC, then the national bracket. Puerto Rico and Virgin Islands pay the lowest amounts.
Watch a recorded webinar to learn more about commission payments CLICK HERE TO VIEW.
Initial payment, true up and pro-rata
In 2025, the max commission for an MAPD sale in CT is $705 with renewals at $353 for the year. That sounds easy enough, but it is not that simple. The amount of commission an agent receives depends on the situation. We provide a breakdown below:
Medicare Advantage commission payments – new to Medicare
If your client is new to Medicare, the carrier pays the full commission in two payments: the intial payment, then the true up payment. The two will total up to the full amount. The renewal commission rate will be half of the full amount and pays over the course of 12 months starting in January. (Regardless of the effective date of the original sale).
New to Medicare Advantage but not new to Medicare
If the client enrolls in a Medicare advantage plan for the first time, the commission is the same as a new to Medicare enrollment. The difference is how the carrier pays it out. The commission is pro-rated. In other words, the payment amount is based on the month the plan is effective. So if someone is enrolled for a June 1 effective date, the agent receives 50% of the full commission. (They will be in the plan for 6 out of the 12 months.) If the person is enrolled for a March 1 effective date, the agent receives 75% of the commission and so on. The renewal starts in January and the agent receives the full renewal amount.
Click here to find out what the 2025 commission rates are
Changing from one Medicare Advantage to another
When your client changes from one MA/MAPD plan to another, the agent receives the same amount when they renew an MA/MAPD plan (half the new enrollment commission). If you enrolled a PA client in an MAPD plan with a Jan 1 start date, the commission is $353. However, plan changes are also pro-rated and if you enroll a PA client in a plan with a March start date, you receive 75% of the $353. In other words, $264.75.
See what to do about non-commissionable PDP plans
Commission payments for AEP
The commission rules do not change during AEP although when agents receive their payment does. Any clients agents enroll during AEP will not pay out until January. Insurance carriers are not permitted to pay them before then enrollment goes into effect. Therefore, most carriers pay out sometime during January.
Use the links below to learn more about our Medicare lead program and T-65 seminar program:
Medicare lead program
Medicare sales seminar program
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For millions of beneficiaries, Medicaid provides a much needed lifeline. This ensures they receive access to essential healthcare services. However, one common question Medicaid beneficiaries have is does Medicaid coverage renew automatically. Although the answer depends on the state and specific circumstances of each enrollee, understanding the Medicaid renewal process helps avoid a lapse in coverage.
Medicaid renewal, also known as redetermination, is the process each state uses to determine if a beneficiary is still eligible for Medicaid benefits. Periodically, each state must verify the beneficiary’s income, household size, and other factors to ensure they still qualify for the program.
Click here to apply for Medicaid in each state
Does Medicaid coverage renew automatically
The short answer is: In some cases, Medicaid renewals are automatic, while others require the beneficiary to provide information to their resident state for renewal.
Automatic (passive) renewal
In many states, if the Medicaid office can verify eligibility through their databases (e.g., tax records, Social Security information, or unemployment benefits), coverage may renew automatically. If this happens, beneficiaries receive a notice in the mail informing them that coverage has been renewed without further action required.
Active Renewals
If eligibility cannot be verified automatically, beneficiaries must complete a renewal form and provide the requested documentation. States may typically send a renewal notice by mail or email depending on the beneficiary’s preferences. The notice includes instructions as well as a deadline to submit the required information.
What Triggers the Need for Renewal
Medicaid renewal usually occurs annually, though the exact timing varies according to when each beneficiary first receives Medicaid. Some reasons for renewal are a change in household size or a change in income. State policies differ and may change and require information for a renewal.
How to prepare for Medicaid renewal
Whether renewal is automatic(passive) or requires action, the following tips can help ensure a smooth process:
Beneficiaries must notify their state Medicaid office immediately if their address, phone number, or email changes. This ensures they receive renewal notices and other important information. They should also watch their mail for important notices and respond quickly. It is also important to keep recent pay stubs, or tax returns as proof of income.
Be aware of the deadline for renewal to respond in a timely manor and avoid a lapse in coverage.
Click here to learn the difference between Medicare and Medicaid
What If the renewal deadline passes
Failing to complete the renewal on time can result in a termination of benefits. However, most states offer a grace period that allows beneficiaries to submit renewal documents and have coverage reinstated retroactively.
Whether renewal is automatic or requires action, keeping your information updated and responding promptly to notices are imperative to maintain benefits.
Additional information
Most states have expanded Medicaid programs that cover anyone with a household income below a specific level.
In each individual state, the Medicaid qualification is based on several factors including income, size of the household, disability or other factors. The specific qualifications vary by state. Some states have expanded Medicaid coverage. When that is the case, Medicaid qualification is based solely on income. Most states accept those with household income less than 133% of the federal poverty level.
It is important to know: every state has a different renewal process for Medicaid beneficiaries. To locate a department of Social services in your area; click here for the department of Social Services.
The Medicare LIS beneficiaries PDP reassignment is completed each year by CMS. CMS reassigns PDP plans for LIS beneficiaries that go over regional LIS benchmarks and do not comply with the accepted premium amount for the following calendar year.
In some cases CMS will also reassign PDPs plans that are terminating in a specified area. This action also applies to MA plans when they are reducing the area they provide service in. In either of these instances, Medicare beneficiaries are enrolled in an alternate plan that is compliant with the LIS benchmarks for the specific area.
What is LIS
LIS (Low Income Subsidy) provides financial assistance with Medicare prescription drug coverage. It is available only to those individuals who qualify based on their income and assets.
Maintaining LIS status
There are four different groups of individuals that have LIS and may require assistance to understand and maintain their status. Each year, CMS sends notices out explaining potential changes to each group on specific colors of paper that corresponds to the group they are in.
Medicare LIS Beneficiaries PDP Reassignment and types of notices
The first group
These are individuals who do not automatically qualify for LIS. In September CMS mails a notice on grey paper to anyone who will no longer automatically receive LIS benefits. Those who receive the grey notice may be eligible for LIS. but they must send in a new application.
Learn more about the Grey notice
The grey notice is an application that explains why their LIS benefit renewal is no longer automatic and requests they send the application in. A postage-paid pre addressed envelope is included with the grey application form.
The second group
Each October, CMS sends out an orange notice to individuals who’s LIS co-payment is changing. These people still qualify for extra help, but the amount will be different than it is currently.
The third group
Individuals in this group receive a blue notice in early November. The blue notice explains that the LIS beneficiaries will be assigned a new Part D plan starting January 1st.
People who are automatically reassigned qualify for a full (100%) subsidy and are currently enrolled in a PDP plan that is raising it’s premium over the approved low premium amount. These individuals were enrolled in their current PDP coverage by CMS. CMS also auto reassigns those who qualify for LIS and are enrolled in a PDP that is leaving the Medicare program.
The fourth group
People who chose their own PDP coverage plan (choosers) receive a notice on tan paper in early November. This notice is sent to those who receive a full (100%) premium subsidy and will have an increase in premium amount. These people will not be reassigned a new PDP plan because they chose their own plan. Therefore individuals can stay in their current plan and pay a higher rate or choose another plan for themselves. The notice includes plan options that provide plans that offer a $0 premium for the beneficiary.
Choosers
What are choosers; they are LIS eligible individuals who receive a 100% premium subsidy and pick their own prescription drug plan. When this is the case, CMS does not enroll these people into a new plan. Although if their chosen plan either terminates or reduces its service area, CMS will enroll them in a plan to avoid a loss of Part D coverage.
View an example of the tan choosers notice
Click here to view a complete guide to CMS consumer mailings 2024/2025
All Medicare agents and potential clients need to understand the Medicare Advantage OEP 2025 Rules to make the most of this opportunity. The Medicare Advantage (MA) Open Enrollment Period (OEP) is an important time when beneficiaries can reassess their healthcare coverage and make changes that better align with their needs. The MA OEP provides one last opportunity for beneficiaries to make an annual plan change and get the coverage they need. It is essential to understand these rules to make informed decisions.
Medicare Advantage OEP
The Medicare Advantage OEP takes place annually from January 1 through March 31. This is an additional opportunity for individuals currently enrolled in a Medicare Advantage plan to:
- Switch to another Medicare Advantage plan (with or without prescription drug coverage).
- Return to Original Medicare and, if they want, enroll in a stand-alone Medicare Part D prescription drug plan.
Important: the OEP is available only to the following individuals:
Rules for the MA OEP
- One-Time Change Rule: Beneficiaries can make only one change during the OEP. Once a beneficiary makes a change, they cannot revise it during the same period. This underscores the importance of careful consideration before making a decision.
- No New Enrollments: Unlike the Annual Enrollment Period (AEP), the OEP doesn’t allow individuals to enroll in a Medicare Advantage plan for the first time. It is strictly for those already in an MA plan or transitioning back to Original Medicare.
- Coverage Start Date: Changes a beneficiary makes during the OEP take effect on the first day of the following month. For example, if the beneficiary changes their plan in March, their coverage begins on April 1.
- Plan Comparison and Guidance: Beneficiaries should compare plans carefully. Factors such as premiums, provider networks, out-of-pocket costs, and prescription drug coverage can vary significantly among plans.
- Special Enrollment Periods (SEPs): The OEP is separate from Special Enrollment Periods, which allow beneficiaries to make changes due to specific circumstances, such as moving out of a plan’s service area or losing other health coverage.
Why the OEP is so important
The Medicare Advantage OEP is a critical time for beneficiaries to evaluate weather their current plan meets their healthcare needs and financial situation. In some instances, they may not have been aware of changes in their current health plan and this provides an opportunity to make necessary changes. Other factors such as changes in health, prescription drug coverage, or provider preferences may contribute to the need to switch plans.
Watch a quick YouTube video on MA OEP best practices
Additionally, each plan updates their benefits and costs annually. Those who did not review their plan details during the AEP have one last opportunity during OEP to make a change. This helps ensure that beneficiaries are not caught off guard by changes that impact their access to care or expenses.
Navigating the 2025 OEP
- Review the annual notice of change (ANOC): Each fall, MA plans send out an ANOC outlining coverage, costs, and provider networks for the upcoming year. Reviewing this document is a great place to start.
- Consult a licensed Medicare agent: Navigating the complexities of Medicare can be overwhelming. A licensed Medicare agent provides personalized advice and can help identify plans that align with each beneficiaries needs.
- Don’t Wait Until the Last Minute: Although the MA OEP runs from January 1 through March 31, making changes early will ensure the beneficiary does not make a hasty decision and provides time to address any issues. Additionally, starting a plan early in the year helps avoid paying multiple plan coverage deductibles.
MA OEP Rules for agents
It is important to remember: agents are prohibited from sending marketing materials targeted to the MA OEP. This is to ensure that agents don’t use the OEP as a specific opportunity to make more sales.
Agents cannot:
- Send unsolicited marketing materials related to the OEP.
- Attempt to convince individuals to use the OEP to make changes. This request must be initiated by the beneficiary who is inquiring about alternative coverage options.
- Agents cannot solicit beneficiaries who enrolled in a plan in the most recent AEP . Again, the beneficiary initiates this not the agent.
Agents who are ready to join the team at Crowe – click here for online contracting
Understanding the rules and opportunities of the Medicare Advantage OEP for 2025 allows agents to help beneficiaries make informed decisions about their healthcare coverage.
In some cases, Medicare beneficiaries miss an enrollment period due to a FEMA emergency. When this happens, beneficiaries may be eligible for a DST SEP. It is imperative that agents are aware of the New Medicare FEMA SEP rules to assist clients. The DST SEP is available to qualified individuals who miss an opportunity to enroll in a Medicare plan.
Medicare FEMA SEP
The DST SEP is an enrollment opportunity CMS offers to Medicare beneficiaries affected by either weather-related emergencies or major disasters. The FEMA SEP lets those who miss a valid election period to either enroll in or disenroll from a Medicare plan. The enrollment takes effect the first day of the month after application is submitted.
This is only available in areas where FEMA, state or other local government officials declare an emergency or disaster. FEMA emergencies start when the incident occurs and lasts for two months up to one year after the start or the extension period begins.
Important changes the the FEMA SEP
On December 3, 2024, CMS released a memo that announced changes to the DST election. These changes go into effect as of April 1, 2025.
If a beneficiary needs to submit an application using the DST election period either on or after April 1, 2025, the application must be submitted directly through CMS. Beneficiaries can call 1-800-MEDICARE or TTY 1-877-486-2048 to submit an application.
In other words, CMS will not accept applications that use the DST election even if they are broker assisted.
Any enrollment application that uses this election will be labeled as using an invalid election period. The plan will then attempt to contact the enrollee and obtain a valid election period. If the plan cannot verify a valid election period, the application will be denied.
Important: missing or invalid elections do not trigger the (RFI) Request for Information process. Therefore, beneficiaries do not have additional time to respond to the inquiry or correct their election.
Please note; applications and disenrollment forms will be updated to remove the DST election.
Reasons to use this SEP
There are varied opportunities to use the SEP. This ensures individuals have the coverage they need.
If the beneficiary resides where a natural disaster (earthquake, flood, wildfire, hurricane, tornado or other specific incident) resulting in a missed valid enrollment period. Sometimes disasters cause beneficiaries to have to leave their home. This may result in them missing their enrollment period and enable the use the FEMA SEP.
The SEP is sometimes available when a beneficiary relies on a family member or other caregiver who is impacted by a disaster and they are unable to assist them during their enrollment period.
Other instances that allow for SEP use include; inability to access Medicare plan information or submit a timely enrollment due to a FEMA declared disaster. Enrollees may also use the SEP when the beneficiary’s healthcare provider of facilities are impacted by the disaster. This can result in the inability to receive necessary information to make an informed decision.
Rules for Eligibility for Medicare Disaster SEP
In order to use the SEP, the beneficiary must live in the are where the disaster occurred. They must have missed a valid enrollment period (AEP, IEP, OEP) during the time of the incident as long as they did not already make a change during the enrollment period. It is also acceptable for those who need assistance from another person to complete the enrollment or make healthcare decisions.
Who cannot use this SEP
Anyone who has already changed their plan during a valid election period can’t use the FEMA election to change it again. Beneficiaries must call 1-800-MEDICARE or TTY 1-877-486-2048 to submit an application in a timely manner to avoid missing their window to enroll.
CMS will begin their Medicare drug price negotiations 2026 with 10 popular high cost prescription medications. CMS has announced the first 10 drugs that will be subject to price negotiations. The negotiations are part of the Inflation Reduction Act. Until recently, Medicare was able to negotiate prices for the medical care beneficiaries receive; this did not include the costs of medications.
If the current plan does not change; on January 1, 2026, the negotiated drug prices for the first 10 drugs will go into effect.
Watch a YouTube video on how to handle non-commissionable PDP plans
Medicare is set to negotiate the cost for some of the more expensive prescription medications with the drug manufacturers.
It is important to note; the negotiations do not apply to drugs that offer a generic equivalent.
The first 10 medications CMS will negotiate are:
- Eliquis (a blood thinner)
- Enbrel (for rheumatoid arthritis)
- Entresto (for heart failure)
- Farxiga (for diabetes, heart failure & chronic kidney disease)
- Fiasp & Novalog (for diabetes)
- Imbruvica (for blood cancers)
- Januvia (for diabetes)
- Jardiance (for diabetes)
- Stelara (for psoriasis & Chron’s disease)
- Xarelto (a blood thinner)
The 10 drugs listed above were chosen because they made up almost 20% of the Medicare Part D spending from June 2022 through the end of May 2023. Medicare Part D covers prescriptions beneficiaries take at home. Part D does not cover medications medical providers administer in medical facilities. When this is the case, Medicare Part B covers the drugs.
Take a look at the drug price negotiation fact sheet
Just the start
The first 10 drugs are just the start of the proposed price negotiations. In 2027, the plan is to add 15 more and the hope is to add more in the years to follow. This plan could change if the drug manufacturers can successfully stop the price negotiations.
Learn about the Medicare prescription payment program.
Drug manufacturers
As it stands, if the drug companies do not agree to the negotiations, they face possible tax penalties. Although drug manufacturers can avoid the tax penalty if they remove their drug from the Medicare market. Unfortunately, if they do that, they take away lifesaving drugs from Medicare beneficiaries and lose a large part of their market share.
Some large drug companies have hired legal counsel to stop the price negotiations. They argue the loss in income will affect their ability to fund important research and development and that in turn, hinders their ability to produce new medicines.
The Negotiation Process
- Drug Selection: Medicare will identify eligible drugs based on spending and clinical impact.
- Price Negotiations: CMS will negotiate directly with manufacturers to establish a “maximum fair price.”
- Implementation: The agreed-upon prices for drugs covered under Medicare Part D will take effect in 2026 with additional drugs phased in over the following years.
Potential benefits
Lower out-of-pocket costs: Beneficiaries could noticeable reductions in their high cost medication expenses.
Federal savings: By reducing the prices for some of the most expensive drugs, the policy could generate substantial savings for Medicare, potentially freeing up funds for other healthcare initiatives.
Health care equity: Lower drug costs may improve access to essential medications for underserved populations.
Concerns
While the policy is praised by some, it is not without controversy.
Impact on innovation: Pharmaceutical companies warn that reduced revenues could lead to decreased availability of funds for research and development. This could potentially slow the pace of medical innovation.
Legal and logistical hurdles: Industry groups have initiated legal challenges, questioning the constitutionality of the negotiation framework. Additionally, the administrative complexities of implementing the program are significant.
Click here to find out about the $2,000 drug cap for 2025
Looking Ahead
As the potential implementation approaches, many groups are watching closely to see what the impact of this policy will be. While challenges remain, the policy’s success could pave the way for broader reforms that could have an effect on the entire healthcare system.
Monitoring both long term and short term effects of this program are essential to determine if Medicare’s negotiating power achieves its intended goals or brings unintended consequences.
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Because navigating Medicare enrollment period options can feel overwhelming, we will explain one specific enrollment opportunity. For beneficiaries seeking flexibility in healthcare coverage, Medicare supplements provide a good option. Because of this, the Medicare Supplement birthday rule is an important policy to understand. This rule, available in certain states, offers a window of opportunity to change Medicare Supplement (Medigap) plans without medical underwriting.
What Is the Medicare Supplement Birthday Rule
The Medicare Supplement birthday rule allows beneficiaries to switch Medigap plans annually around their birthday without undergoing medical underwriting. This means insurers cannot deny coverage or charge higher premiums based on health status during the designated timeframe.
Medicare supplement plans help cover out-of-pocket costs not paid by Original Medicare, such as copays, coinsurance, and deductibles. However, outside of the initial enrollment period, switching plans typically requires medical underwriting, which can be a barrier for those with pre-existing conditions. The birthday rule removes this obstacle during its specific enrollment window.
States That Have the Birthday Rule
As of now, the Medicare Supplement birthday rule is not a federal policy; it is enacted at the state level. Currently, 8 states including California, Idaho, Illinois, Kentucky, Louisiana, Maryland, Nevada and Oregon have implemented variations of this rule. Each state’s version differs slightly in terms of timing and eligible plans:
California
Beneficiaries have 60 days from the first day of their birth month to switch Medicare supplement plans to enroll in one with the same or a less benefits. They also have the option to switch insurance carriers during this period.
Idaho
Those who reside in ID have 63 days from their birthday to switch Medicare supplement plans with the either the same or less benefits. They can also switch to another insurance carrier if they like.
Illinois
Beneficiaries in IL have 45 days from their birthday to change Medicare supplement plans with either the same or less benefits. This rule only applies to plans with the existing insurance carrier or an affiliate of the current carrier. The affiliate carrier was added in 2024. In order to To qualify for the birthday rule in IL, beneficiaries must be between 65 and 75.
Kentucky
As of 1-1-24, KY allows Medicare supplement enrollees to switch to another supplement carrier that offers a plan with the same benefits as their current plan. They must switch within 60 days of their birthday.
Louisiana
In the state of LA, beneficiaries are given 63 days from their birthday to switch to another Medicare supplement plan with equal or lesser benefits. Enrollees are only permitted to enroll in a plan offered by either their current carrier or an affiliate of their current insurer.
Maryland
As of July 1. 2023, beneficiaries have 30 days from their birthday to change Medicare supplement plans with either equal or less benefits than their current plan.
Nevada
In the sate of NV, the birthday rule allows beneficiaries 60 days form the first day of their birthday month to change supplement plans to one with the same or less benefits. It is also permitted to switch insurance carriers.
Oregon
Beneficiaries have 30 days from the first day of their birth month to switch Medicare supplement plans to another with the same or fewer benefits. They can also change insurance carriers.
Please note; beneficiaries and their agents must verify the state specific rules and timelines.
Watch a quick YouTube video on Medicare enrollment periods
How the Birthday Rule works
Each year plan enrollees should evaluate their current supplement coverage and decide if it still meets their needs. A licensed Medicare agent can help compare available plan options to find one that best suits the needs of the enrollee. They will also be able to advise of the applicable enrollment window using the appropriate birthday rule for each eligible state.
Beneficiaries must submit all applications before the enrollment period ends. Insurers cannot deny applications submitted during the birthday rule period. They are also prohibited from increasing premiums based on health conditions.
Benefits of the Birthday Rule
The birthday rule provides several advantages for beneficiaries. This includes the ability to adjust their coverage to better align with their healthcare needs and budget. It also allows enrollees an opportunity to change plans without fear of rejection.
Considerations for Beneficiaries
Although the birthday rule provides some significant benefits, there are a few important considerations:
State-Specific Rules: The availability and details of the birthday rule depend on where each beneficiary resides. It is not available in every state.
Plan Restrictions: In general, the rule applies only to plans that offer equal or lesser benefits, so beneficiaries cannot use it to upgrade coverage.
Timing: Those who miss the enrollment window must wait until next year’s birthday period to change plans.
Learn about Medigap guarantee issue rules; click here
The Medicare Supplement birthday rule is valuable for eligible beneficiaries. It provides an annual opportunity to change coverage without medical underwriting.
Now that is 2025, both Medicare beneficiaries and agents need to know what the Medicare premiums and deductibles 2025 are so that everyone can plan accordingly. 2025 is the same as previous years; CMS has made changes to both Medicare Part A & Part B premiums and deductibles.
Medicare Part A costs 2025
The majority of beneficiaries do not have to pay a Part A premium if they have worked for at least 40 quarters (10 years) and paid Medicare taxes. Although if they do not qualify for premium free Part A, there are a couple different premium amounts they can pay if they want Part A benefits.
When either the beneficiary or their spouse worked and paid Medicare taxes between 30 and 39 quarters, the monthly premium cost is $285 in 2025. This is an increase of $7 from the 2024 cost of $ 278.
If the beneficiary or their spouse worked at a job and paid Medicare taxes for less than 30 quarters, the premium in 2025 is $518. This an increase of $13 from the cost of $505 in 2024
Part A Deductible and Coinsurance 2025
Part A covers inpatient hospital costs. In 2025, the Part A deductible has gone up $1,676 for each benefit period. This is an increase of $44 from the cost of $1,632 in 2024.
On original Medicare once the beneficiary meets the deductible, the cost for a hospital stay is $0 for days 1-60. The cost for days 61-90 is $419 per day. This is $11 over the cost of $408 in 2024. Once the beneficiary reaches day 91 and over, they start to use their lifetime reserve days and pay $838 per day. that is up from $816 in 2024.
There is no coinsurance charge for days 1-20 in skilled nursing facility stays. The cost for days 21-100 are $209.50 per day in 2025. This is a $5.50 increase from the 2024 cost of $204.
Click here to learn about the Part D drug cap
Part B costs 2025
In contrast to the Part A premium, almost all beneficiaries have to pay a Part B premium. In special circumstances, if a beneficiary qualifies for extra help due to limited income and resources, they may not have to pay the Part B premium.
Part B Premiums & Deductibles
For 2025, the standard monthly premium has gone up $10.30 to $185.00. The premium was $174,70 in 2024.
Learn more about Part B costs
Those with an income level over a specified amount pay an IRMAA. The CMS adds the IRMAA to the standard monthly premium amount. The premium amount each beneficiary pays ranges from $259 to $628.90 per month if the beneficiary pays an IRMAA. The amount is based on their specific income level.
If you have been incorrectly charged an IRMAA, learn how to file an appeal.
The deductible amount for Part B in 2025 is $257, an increase of $17 from the 2024 cost of $240.
It is important for beneficiaries to stay updated on healthcare costs each year to manage their budgets and avoid surprises. CMS makes decisions on Medicare costs based on the projected rise in costs and use of healthcare.
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There are several ways to get more Medicare referrals. Medicare referrals are a fantastic, no cost way to grow your book of business. Once agents are established as a community resource may rely solely on referrals and do not have to spend money on other lead sources.
Build good relationships with your existing clients
Smart agents make sure they are available to answer any questions or concerns their clients have. This goes a long way to build client relationships. The most important thing you can do as an agent is to listen to your clients to understand their coverage needs and wants. Once they know you have their best interest at heart and provide good service, they are happy to recommend you to their friends and family.
It is important to stay in contact with your clients. This way they remember you are there for them and they do not ask another agent for assistance.
Contacting every client before AEP is another way that helps you stay in contact and also allows you to update their information before it is time to choose a plan for the coming year.
Sunfire and Connecture quoting and enrollment tools 2025 update
When a potential client contacts you be sure to Collect their contact information; email and phone to help you stay in contact if they give you permission to do so. This way agents can send out informational emails or contact a client if needed. I some instances, agents can use phone numbers to contact clients via text message, if the prospect gives permission and you provide the option to opt out. Texts can be a quick and easy way to provide general information to a large number of clients at once.
Watch a YouTube video on AEP marketing rules
Online presence
A strong online presence is essential in today’s digital age. Agents should create a business profile on social media. Once you create the profile, it is imperative to update the platform with information potential clients may find helpful. General information on Medicare choices and answers to common questions are good ways to engage readers and encourage repeat visits to your platform. An online presence has the capability of reaching a very large audience and presents you as knowledgeable resource in the field of Medicare.
Let Pinnacle help build your insurance website
Educational workshops
Hosting free Medicare workshops or webinars helps educate the community about coverage options and changes in Medicare. When you provide valuable information to those who need help, you gain credibility as a valuable resource. Those who attend may refer friends or family to you for guidance when they need help with their Medicare options.
Learn the best practices for educational seminars, click here
Referral Incentives
Be sure to thank those who refer new clients to you with a small gift. Please note; incentives can include a gift card or anything appropriate with a value of not more than $15 that cannot be easily converted into cash. It is extremely important to be complaint when you offer a referral gift. Acknowledging and appreciating referrals encourages your existing clients to actively promote your business.
For referrals that you receive from other agents or professionals (ACA agents, P&C agents, other Medicare agents), referral gifts of up to $100 per sale is allowable. Remember to send the payment so they refer more clients to you. Please note in most cases, financial planners cannot accept the referral gift.
If you have a client that is happy with the service you provide, you can ask them for referrals if you do it in a way that you are both comfortable with.
Collaborate with Local Businesses
Build relationships with local businesses that serve the senior population. Think about making connections with senior centers, fitness clubs, retirement communities or other local services. These relationships can be mutually beneficial, as you you can refer clients to one another.
Introduce yourself to local healthcare providers, clinics or care facilities. Once they know you and the service you provide, they may form a partnership with you. Having a good rapport with these providers opens doors to a new stream of leads.
Consider volunteering at local healthcare events and workshops to connect with providers and potential clients. Other professionals can refer people who need assistance with Medicare coverage. This also helps establish you as a reliable resource for Medicare coverage needs.
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Stay up to date on Medicare plans and regulations
Agents need to stay educated on all available plan options as well as compliance rules. Be sure to attend product training sessions, workshops and conferences. Broker managers and other agents are both sources of potential referrals if they have a beneficiary who needs assistance in your area. A well informed and well-known agent is more likely to attract referrals from clients and other professionals.
A large referral network is a great way for MEdicare agents to achieve long-term success. Focusing on client satisfaction and following the suggestions above can help agents build a successful business that brings in new clients and more opportunities.