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CMS Proposes Star Ratings Change for Medicare Advantage & Part D Plans

Federal regulators are moving to revamp the Medicare Advantage Star Ratings program, signaling a shift in how insurers’ performance is measured and rewarded. The Centers for Medicare and Medicaid Services CMS Proposes Star Ratings Change; they issued a draft regulation, opening the door for public input on potential changes to Medicare Advantage policies, risk adjustment, and even the Medicare Part D prescription drug program.

The proposed overhaul comes as insurers face mounting pressure from prior authorization requirements, audits, and marketing restrictions. By streamlining the Star Ratings system, CMS may offer plans some relief while keeping the focus on high-quality patient care.

Watch a YouTube video on the discontinued Medicare Advantage special enrollment period

What’s Changing in Star Ratings

The Star Ratings program has significant financial implications for insurers. CMS awards Medicare Advantage and Part D plans that score at least four stars with a 5% payment bonus. Under the draft rule, the agency proposes removing a dozen measures that focus on operational performance or administrative processes rather than clinical outcomes.

Of the changes, eight measures would affect only Medicare Advantage plans, two would apply only to Part D, and two would apply to both programs. Examples include removing metrics tied to appeal decision timeliness, customer service, and members’ decisions to leave a plan. CMS notes that these measures “don’t sufficiently convey variations in quality among plans.” Most of the changes would take effect for the 2029 plan year.

Health Equity Index Eliminated

CMS also proposes ending its Health Equity Index, a 2024 initiative that rewarded plans for improving care for marginalized populations. Instead, the agency would continue the existing reward factor that incentivizes high performance across measures.

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New Focus on Clinical Care

The draft regulation highlights CMS’s intent to refocus Star Ratings on meaningful clinical outcomes. For example, the agency plans to add a depression screening follow-up measure to Medicare Advantage, reflecting an emphasis on behavioral health.

“These proposed changes aim to refocus the program on clinical care, outcomes and patient experience where there is meaningful variation in performance across contracts,” CMS said in a news release.

What This Means for Insurers and Beneficiaries

Insurers could benefit from a simpler Star Ratings system, with less emphasis on administrative metrics. For beneficiaries, the changes signal a stronger focus on health outcomes and patient experience rather than operational benchmarks. The public now has a chance to weigh in on the proposals before CMS finalizes the rule.

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

Wellabe Hospital Indemnity Plan Sales – An Opportunity for Medicare Agents

As Medicare Advantage benefits continue shifting and out-of-pocket costs trend upward, 2026 is shaping up to be a year where supplemental protection becomes more important than ever. That’s why Wellabe Hospital Indemnity plan sales are emerging as a strong add-on product. This is helpful for agents looking to boost client value, deepen relationships, and increase commissions all while solving real coverage gap issues for Medicare beneficiaries.

Below is an original, agent-focused breakdown of why Wellabe HI plans deserve a top spot in your sales strategy.

Why Hospital Indemnity Plans Matter in 2026

Even with Medicare Advantage coverage, your clients face unpredictable and sometimes steep costs when they’re admitted to a hospital. MA plans commonly include:

• Daily inpatient copays
• Emergency room copays
• Observation stay costs
• Ambulance fees
• Rising maximum out-of-pocket (MOOP) limits

Hospital Indemnity plans fill these financial gaps by providing cash benefits paid directly to the member, which can be used for anything; copays, transportation, lodging for family members, or simply covering monthly bills.

With many MA carriers adjusting benefits and tightening budgets for 2026, more clients are feeling the strain of increased cost-sharing. This shift creates a prime selling opportunity for Wellabe’s Hospital Indemnity Plan.

Why Agents Love Wellabe’s HI Product

Wellabe (formerly Great Western Insurance Company) has structured their HI plan to be flexible, easy to present, and competitive nationwide.

Simplified Issue for Most Ages

Clients can often qualify without medical exams or lengthy underwriting. Fast approvals mean a smoother sales process for both you and the client.

Highly Customizable Benefits

You can tailor benefits based on a client’s specific MA plan design. Options include:

• Daily hospital confinement benefits
• Ambulance coverage
• Observation stay riders
• Skilled nursing facility benefits
• ER coverage
• Lump-sum outpatient surgery benefits

This allows you to build a package that aligns perfectly with their needs.

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Affordable Monthly Premiums

Wellabe’s pricing remains competitive, especially for clients in their late 60s and early 70s. HI plans are one of the easiest cross-sell items because premiums are low and the value is easy to demonstrate.

Ideal Cross-Sell with Medicare Advantage

Whenever you review a client’s MA plan and see hospital copays or multi-day confinement fees, you have a natural opening to present Wellabe HI as a cost-protection solution.

Learn how to cross sell – watch our quick YouTube video

Sales Positioning That Works

Here are proven strategies you can use during AEP, OEP, or everyday sales conversations:

Create Security

Highlight the unpredictable nature of hospital expenses with MA plans. Clients appreciate having fixed, guaranteed cash benefits.

Protect Your Retirement Income

Explain how a short hospital stay could wipe out a month, or more, of income. A low-cost HI plan helps stabilize finances.

Match Benefits to Plan Gaps

Show them the exact hospital copay amounts in their MA plan and how a Wellabe HI benefit can cover it dollar-for-dollar.

Bundle Approach for Agents

Many agents use wording similar to the following:
“If you choose an MA plan, you might wan to consider pairing it with a Hospital Indemnity plan so your hospital costs are fully covered.”

This increases client satisfaction and reduces future complaints or surprise bills.

Why Selling Wellabe HI Plans Builds Long-Term Business

• Strong customer service and claims reputation
• Additional commission without added complexity
• Deepens your advisory role with every client and allows them to use one resources for their coverage needs

Clients who feel fully protected are less likely to shop around, helping you retain business year after year.

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Medicare Supplement Plan Sales Growth

As Medicare Advantage plans undergo major changes for 2026, more seniors are taking a closer look at Medicare Supplement (Medigap) coverage. With tighter MA budgets, reduced benefits, and growing network concerns, Medigap is becoming the go-to choice for beneficiaries who want simplicity, stability, and predictable healthcare costs. This has helped with Medicare Supplement plan sales growth.

Why Medicare Advantage Changes Are Driving the Shift

For 2026, many Medicare Advantage carriers are reducing cost-sharing perks, scaling back extras, and becoming more selective with enrollment growth. Factor in increased marketing scrutiny and commission pressure, and the MA landscape feels less predictable than it has in years.

Seniors are noticing; many are now reevaluating whether MA plans still fit their needs.

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Why Medicare Supplement Plans Stand Out in 2026

1. Predictable Costs and Simple Coverage

Medigap helps shield members from unexpected bills by covering the gaps in Original Medicare. Plan G and other popular options remain consistent year after year.

2. Freedom From Networks

Members can see any doctor or hospital nationwide that accepts Medicare; no referrals, no authorizations, and no surprises.

3. Long-Term Stability

While MA benefits change annually, Medigap benefits do not. This makes Medigap especially appealing amid shifting MA offerings.

How to Position Medigap in Your Sales Strategy

• Lead with predictability: Emphasize long-term cost stability compared to fluctuating MA benefits.
• Highlight provider freedom: Seniors frustrated with shrinking MA networks respond well to Medigap’s nationwide access.
• Target MA switchers: Many beneficiaries use the Medicare Advantage Open Enrollment Period to move into more stable coverage.
• Educate early: Start conversations before annual plan changes create confusion or frustration.

Watch a quick YouTube video on MA OEP best practices

Key Takeaways

• Medicare Advantage plans are cutting back on supplemental benefits and tightening networks for 2026.
• Medicare Supplement plans offer predictability, nationwide access, and long-term stability.
• Demand is increasing as seniors seek more control and fewer surprises.
• Agents can leverage this shift to build trust, long-term relationships, and stronger retention.

As Medicare Advantage plans tighten benefits in 2026, Medicare Supplement insurance stands out as a stable, reliable alternative. For agents, this shift presents a strong opportunity to guide clients toward coverage that offers flexibility, control, and predictable healthcare spending.

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Medicare Part B Enrollment Periods

Medicare Part B is a vital part of your healthcare coverage, helping to pay for doctor visits, outpatient care, preventive services, and medical supplies. However, knowing when to sign up is just as important as understanding what Part B covers. Enrolling at the right time ensures you avoid costly late penalties and gaps in coverage. Here’s a breakdown of the key Medicare Part B enrollment periods and what each means for you.

Initial Enrollment Period (IEP)

Your Initial Enrollment Period is your first chance to enroll in Medicare Part B. It lasts seven months — beginning three months before, including your birth month, and continuing three months after you turn 65.

• If you enroll before your birthday month, your Part B coverage starts the month you turn 65.
• If you enroll during or after your birthday month, coverage begins the month after you enroll.

Tip: Even if you’re still working, check with your employer’s HR department to see whether you should enroll right away or delay Part B to avoid duplicate coverage.

Special Enrollment Period (SEP)

If you or your spouse are still working past 65 and have employer-sponsored health coverage, you can delay enrolling in Part B without penalty. Once that coverage ends, you qualify for a Special Enrollment Period.

The SEP lasts eight months from the date your employment or group coverage ends — whichever comes first. Enrolling during this window ensures you don’t face the Part B late enrollment penalty, which can increase your premium by 10% for every 12 months you were eligible but didn’t sign up.

Important: COBRA or retiree coverage doesn’t count as active employer coverage, so your SEP clock may start ticking sooner than you think.

Watch a YouTube video on Medicare OEP, SEPs and Late Part B Enrolllments

General Enrollment Period (GEP)

If you missed both your Initial and Special Enrollment Periods, the General Enrollment Period gives you another chance. The GEP runs every year from January 1 to March 31.

• Coverage begins the first day of the month after you enroll.
• You may owe a late enrollment penalty added to your monthly premium for as long as you have Part B.

While this period can be a helpful safety net, it’s best to avoid relying on it if possible due to potential penalties and delayed coverage.

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Medicare Advantage (Part C) and Other Related Enrollment Periods

Once you have Part B, you can explore Medicare Advantage (Part C) or Medigap plans to supplement your coverage. Enrollment in these plans often depends on your Part B effective date, so timing your Part B enrollment correctly is crucial for coordinating your full Medicare coverage.

Understanding Medicare Part B enrollment periods can save you money and prevent headaches down the road. Whether you’re turning 65 soon, working past retirement age, or helping a loved one with their coverage decisions, planning ahead is key.

If you’re unsure when to enroll, a licensed Medicare agent can review your situation, explain your options, and help you avoid penalties or coverage gaps.

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Why Offer Cigna CHS Plans – A Smart Add-On for Today’s Medicare Market

Why offer Cigna CHS plans; in today’s shifting healthcare landscape, consumers are more concerned than ever about unexpected medical costs. This is especially true of those triggered by major health events like cancer, heart attacks, and strokes. For agents, this concern represents a major opportunity. Cigna’s Cancer, Heart Attack & Stroke (CHS) plans have quickly become one of the most valuable supplemental products to offer alongside Medicare Advantage, Medigap, and individual health insurance.

Here’s why CHS coverage should be part of your 2026 sales strategy.

CHS Plans Fill a Critical Financial Gap

Cancer, heart attacks, and strokes are among the costliest and most common medical events for U.S. adults. Even insured clients often face:

• High deductibles and co-pays
• Hospitalization charges
• Travel and lodging for treatment
• Lost income or caregiver costs

Cigna’s CHS plans provide a lump-sum cash benefit clients can use for anything; medical or non-medical. This flexibility allows families to stay financially stable during the most stressful moments of their lives.

Watch a quick YouTube video on ancillary plan sales

Cigna Offers Strong, Recognizable Branding

Cigna is a trusted national name, and clients feel confident purchasing protection from a carrier they already associate with quality and service. This instantly boosts your credibility and reduces objection rates that often happen with lesser-known supplemental carriers.

Simple, Streamlined Underwriting

Cigna’s underwriting for CHS plans are straightforward, agent-friendly, and designed for quick approvals. This makes CHS an easy add-on during:

• Medicare Advantage reviews
• Medigap comparisons
• ACA Special Enrollment conversations
• Life insurance appointments

Faster underwriting means more closed sales and fewer follow-ups.

Competitive Premiums & High Value for the Client

CHS premiums remain very affordable; even for clients on a fixed income. For many households, adding this coverage costs less per month than common streaming subscriptions. Yet the payout during a claim can be life-changing.

For agents, this creates a high-value, low-resistance product that clients appreciate and rarely cancel.

A Perfect Cross-Sell During Annual Reviews

If you’re an active Medicare agent, you’re already meeting clients every year. CHS coverage fits seamlessly into that conversation:

“Your current plan looks good, but let’s also talk about financial protection if something major happens.”

These products can add revenue, boost client retention, and strengthen your role as a full-service advisor.

Easy to Explain, Easy to Sell

You don’t need complex charts or benefit summaries. Clients understand cancer, heart attacks, and strokes; they’ve seen friends, family, or coworkers experience them. The product is relatable and instantly makes sense.

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Helps Protect Your Book of Business

When you offer supplemental solutions that truly help clients, they are far more likely to stay with you long-term. CHS adds stickiness to your business and positions you as a proactive agent who delivers value, not just someone who enrolls clients into a single plan.

Cigna’s Cancer, Heart Attack & Stroke plans are one of the simplest and most impactful products you can add to your portfolio in 2026. They support your clients, improve financial security, and create a reliable revenue stream for your business.

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

If you’re looking for a product that offers strong benefits, easy conversations, and meaningful protection; Cigna CHS is a must-have in your lineup.

Medicare Costs 2026: What Beneficiaries and Agents Need to Know

As Medicare undergoes significant shifts in 2026, beneficiaries will face new premiums, deductibles, and cost-sharing structures. These costs impact how they access and budget for care. For agents, understanding these changes is essential for guiding clients through enrollment decisions and helping them prepare for the year ahead. Here’s a breakdown of important Medicare cost updates for 2026 and what they mean for the people you serve.

Higher Costs Driven by Utilization and Program Changes

Several factors are driving cost increases across Medicare Part A and Part B in 2026:

• Greater healthcare utilization: Hospital and outpatient visits continue to rise.
• Higher reimbursement requirements: Centers for Medicare & Medicaid Services (CMS) is adjusting payments to hospitals, physicians, and Medicare Advantage plans due to inflation and increased care complexity.
• Changes in Medicare Advantage rules: Policy shifts for 2026; including tighter oversight and reduced supplemental benefit flexibility, are indirectly affecting Original Medicare spending trends.

While Medicare costs rise most years, 2026 brings a more noticeable increase driven by combined economic and regulatory pressures.

Medicare Part A Costs for 2026

Most beneficiaries still receive Part A with no monthly premium (if they qualify via work-history) but other Part A cost-sharing amounts are increasing:

• Inpatient hospital deductible (Part A): For 2026 the deductible for a benefit period is $1,736, up from $1,676 in 2025.
• Daily coinsurance for days 61–90 in hospital: $434 per day in 2026, up from $419.
• Lifetime reserve-day coinsurance: $868 per day in 2026.
• Skilled Nursing Facility (SNF) coinsurance (days 21-100): $217 per day in 2026, up from $209.50.

Agents should remind clients that even if Part A premium is “free,” they can still face significant out-of-pocket exposure via hospital stays and extended care—making Medigap or a well-selected Medicare Advantage plan even more important.

Medicare Part B Costs for 2026

Part B sees some of the most direct increases:

• Standard monthly premium (Part B): $202.90 per month in 2026 (up from $185.00 in 2025).
• Annual deductible (Part B): $283 in 2026 (up from $257 in 2025).
• Income-related monthly adjustment amounts (IRMAA): Beneficiaries with higher incomes will pay more than the standard premium; for 2026 the standard premium applies to individuals with a modified adjusted gross income (MAGI) up to $109,000 (or $218,000 for joint filers)

For agents, breaking down these numbers early in AEP and during SEP conversations helps clients avoid sticker-shock and budget accurately.

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Prescription Drug Costs

• The annual deductible for the standard Part D benefit in 2026 is $615.
• Beneficiaries will pay cost-sharing (typically coinsurance) during the initial coverage phase until their true out-of-pocket (TrOOP) drug spending hits $2,100 for 2026. At that point, the plan pays 100% of covered drugs for the rest of the year.
• All 2026 Part D plans are required to include this $2,100 cap.
• For beneficiaries with very high drug costs, this cap provides meaningful protection, limiting their maximum annual out-of-pocket prescription drug expense (excluding premiums).

Learn more about the drug cap – watch a YouTube video

Medicare costs are rising in 2026; with thoughtful planning, beneficiaries and their agents can manage these changes with confidence. By staying informed and proactively communicating updates, agents stand out as trusted, knowledgeable guides.

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Fewer Medicare Ads This year

If it feels like you’re seeing fewer Medicare commercials this year, you’re right; and there’s a strategic reason behind it. Medicare Advantage (MA) carriers are reshaping their marketing approach, scaling back traditional outreach, and rethinking how they attract new members. The shift is driven by tighter budgets, lower margins, and a growing need to stabilize enrollment rather than fuel massive growth.

Carriers Are Controlling Enrollment Growth

One of the biggest changes this year is that some Medicare Advantage insurers don’t actually want huge spikes in enrollment. After facing higher-than-expected medical costs and reduced federal payments, carriers are trying to manage their risk pools more carefully. For some companies, adding too many new members; especially in a short period, can strain budgets and hurt profit margins. As a result, they are intentionally easing up on aggressive recruitment.

Watch a YouTube video in Medicare Enrollment Periods

Cost-Control Drives Marketing Cutbacks

Traditional Medicare marketing is expensive. TV spots, large call centers, and massive direct mail campaigns require big budgets. Many insurers are pulling back to control costs and protect their financial outlook for 2026 and beyond. Instead of blasting ads all over every network, carriers are shifting toward more targeted and cost-efficient approaches.

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Retention Over Recruitment

Rather than chasing every possible new enrollee, insurers are shifting their focus toward retaining current members. Improving member experience, reducing churn, and keeping satisfaction high are now more important than driving big enrollment surges. Retention is cheaper; and often more profitable than acquiring new members.

Direct Mail Is Losing Priority

Direct mail has long been a cornerstone of Medicare Advantage marketing, but its impact has diminished. High printing and postage costs combined with lower response rates mean fewer carriers are using it at the scale they once did. You’ve probably noticed fewer flyers and brochures in your mailbox because insurers simply aren’t sending as many.

Digital Channels Are the New Frontier

As today’s “younger seniors” age into Medicare, insurers are turning to online channels to reach them. Social media, paid search, email, and educational video content allow companies to connect with tech-comfortable beneficiaries in a more targeted and cost-effective way.

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

Medicare A and B Basics

Understanding Medicare can feel overwhelming at first, but it becomes much simpler once you break it down into the two core parts of Original Medicare: Part A and Part B. These two components form the foundation of Medicare coverage and help beneficiaries access essential hospital and medical care. Whether you’re approaching age 65 or helping a loved one navigate enrollment, here’s the Medicare A and B Basics.

What Medicare Part A Covers (Hospital Insurance)

Medicare Part A is often called hospital insurance because it helps cover care you receive in a hospital or similar inpatient setting. Most people receive Part A premium-free as long as they or their spouse worked and paid Medicare taxes for at least 10 years.

Part A covers:

Inpatient Hospital Care

This includes semi-private rooms, meals, nursing care, medications given in the hospital, and other hospital services. Part A does not cover private rooms unless medically necessary.

Skilled Nursing Facility (SNF) Care

Part A may cover care in a skilled nursing facility after a qualifying three-day inpatient hospital stay. This is not long-term custodial care, but medically necessary rehabilitation services such as physical or occupational therapy.

Home Health Care

If ordered by a doctor and medically necessary, Part A can help cover intermittent skilled nursing care, physical therapy, or speech therapy delivered in the home.

Hospice Care

For patients with a terminal illness and a prognosis of six months or less, Part A provides comprehensive hospice benefits, including pain relief, symptom management, and family support.

Part A Costs

Most beneficiaries pay no monthly premium, but deductibles and coinsurance still apply. For example, there is a per-benefit-period deductible for hospital stays and daily coinsurance after certain lengths of inpatient care.

Watch a YouTube video on Medicare Enrollment Periods

What Medicare Part B Covers (Medical Insurance)

Medicare Part B is medical insurance that covers outpatient and physician services. Unlike Part A, everyone pays a monthly premium for Part B, and higher-income beneficiaries may pay more.

Part B covers:

Doctor Visits

This includes primary care, specialists, and certain preventive screenings and exams.

Outpatient Services

Such as X-rays, lab work, outpatient surgeries, and emergency room or urgent care services (when not admitted as an inpatient).

Durable Medical Equipment (DME)

Items like walkers, wheelchairs, CPAP machines, and home oxygen equipment.

Preventive Care

Medicare Part B provides a wide range of preventive services at no extra cost when using participating providers; annual wellness visits, vaccines, mammograms, colonoscopies, and more.

Mental Health Services

Includes outpatient therapy, psychiatric evaluations, and some partial hospitalization programs.

Part B Costs

Beneficiaries pay a standard monthly premium, an annual deductible, and typically 20% coinsurance for most covered services. Part B has no out-of-pocket maximum unless you pair it with a Medigap plan or choose a Medicare Advantage plan.

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How Medicare A & B Work Together

Part A and Part B complement each other to provide broad medical coverage. Part A focuses on inpatient care, while Part B handles outpatient and ongoing medical needs. Many people choose to add:

• A Medicare Supplement (Medigap) to reduce out-of-pocket costs
• A Part D prescription drug plan
• Or a Medicare Advantage plan that bundles A, B, and often D into one

Your choice depends on your budget, health needs, and preferred style of coverage.

Understanding the basics of Medicare Parts A and B is the first step in building reliable coverage for your healthcare needs. By knowing what each part covers and what it doesn’t; you can make confident decisions as you prepare for enrollment or compare additional coverage options

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Medicaid and Long-Term Care

When it comes to paying for long-term care, many families are surprised to learn that Medicare doesn’t cover most long-term care costs. That’s where Medicaid can step in as a vital resource. For seniors and individuals with limited income and assets, Medicaid can help cover the high cost of nursing home care and, in some cases, in-home or assisted living services. However, the rules can be complex and understanding how Medicaid and long-term care work together can be important to planning ahead.

Medicaid coverage of Long-Term Care

Medicaid is a joint federal and state program that helps people with low income and limited resources pay for healthcare. One of its most important benefits is coverage for long-term care services, such as:

• Nursing home care (room, meals, skilled nursing, and personal care)
• Home and community-based services (HCBS) like in-home aides, adult day care, or home modifications
• Assisted living services in some states

Because Medicaid is managed by each state within federal guidelines, coverage details and eligibility requirements vary depending on where you live.

Financial Eligibility: Income and Asset Limits

To qualify for Medicaid long-term care, applicants must meet strict financial and functional requirements.

Most states have both:

• Income limits — based on a percentage of the federal poverty level or a fixed monthly cap.
• Asset limits — typically allowing applicants to keep only a small amount in countable resources (often around $2,000 for an individual).

However, not all assets are counted. For example, your primary residence (up to a certain equity limit), one vehicle, personal belongings, and certain burial funds may be excluded.

Couples have special rules called “spousal impoverishment protections”, which allow the healthy spouse to retain a portion of income and assets so they are not left destitute.

Functional Eligibility: Level of Care Requirements

In addition to financial need, applicants must demonstrate a medical need for long-term care. Each state has criteria to determine whether a person requires nursing home level of care; such as needing assistance with multiple daily activities (bathing, dressing, eating, toileting, or mobility).

Medicaid Estate Recovery

It’s important to note that Medicaid can seek repayment for long-term care costs from the estate of the deceased beneficiary. This process, called estate recovery, generally occurs after the recipient’s death, often through the sale of property or assets left behind. However, exceptions and delays may apply if there’s a surviving spouse or dependent child.

Watch a YouTube video on LTC and Alternatives

Home and Community-Based Waivers (HCBS)

Many states now offer Medicaid waivers that allow people to receive care at home or in community settings rather than in nursing homes. These programs help individuals remain as independent as possible while still receiving support services. Waiver programs often have limited slots and waiting lists, so early planning is essential.

The Importance of Planning Ahead

Medicaid long-term care planning can be complex; involving income limits, asset transfers, and look-back periods (typically five years). Attempting to give away assets or transfer property before applying can trigger penalty periods of ineligibility.

Working with a qualified elder law attorney or Medicaid planning specialist can help families understand their options, protect assets legally, and prepare for future care needs.

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Medicaid is a lifeline for many Americans who need long-term care but cannot afford it privately. By understanding the program’s eligibility rules, coverage options, and planning strategies, families can make informed decisions that protect both their health and their financial well-being.

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Understanding Medicare Part D Coverage

Medicare Part D is the portion of Medicare that helps pay for prescription drugs, providing essential coverage for those who rely on medication. While Part D plans differ, they all follow general Medicare guidelines. This makes understanding Medicare Part D coverage a little easier. Here’s a breakdown of what Part D covers, and what it does not cover, to help avoid surprises at the pharmacy.

What Medicare Part D Covers

Medicare Part D plans are offered by private insurance companies, and each plan has its own formulary, or list of covered medications. Still, all plans must include a wide range of commonly used prescription drugs.

Retail and Mail-Order Prescriptions

Part D primarily covers medications you pick up at a pharmacy or receive through mail-order. Drugs are grouped into tiers, which determine your copay or coinsurance.

Essential Drug Classes

Plans must include at least 1 medication in each key category such as:

• Antidepressants
• Antipsychotics
• Immunosuppressants
• HIV/AIDS medications
• Anticonvulsants
• Some oral cancer drugs not covered by Part B

Certain Vaccines

Part D pays for vaccines not covered by Part B, including the shingles vaccine.

Insulin and Related Supplies

Many plans have capped insulin costs and cover supplies like needles and syringes.

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What Medicare Part D Does Not Cover

While Part D covers many prescriptions, several important exclusions apply.

Drugs Given in a Hospital

If you’re admitted as an inpatient, medications provided during your stay are covered under Medicare Part A, not Part D.

Medications Administered in a Doctor’s Office

Any drug that must be given by a healthcare professional; such as injections, infusions, or biologics, is usually covered under Medicare Part B.

Examples include:

• IV antibiotics
• Chemotherapy infusions
• Injectable osteoporosis treatments

Over-the-Counter Products

Part D does not cover vitamins, supplements, or OTC medications unless a plan offers them as an added benefit.

Watch a YouTube video on the $2K drug cap

Cosmetic and Weight-Loss Medications

Most drugs used for cosmetic purposes or weight reduction are excluded.

Non-Formulary Drugs

If a drug isn’t listed on a plan’s formulary, it generally won’t be covered unless your doctor requests and the plan approves a formulary exception.

Experimental Drugs

Any medication that is not FDA-approved is excluded.

Medicare Part D is a valuable benefit, but understanding what it covers and doesn’t, helps you choose the right plan and avoid unexpected costs. Reviewing formularies and pharmacy networks each year ensures you get the most from your prescription drug coverage.

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Medicare Advantage Compensation Loss – State Regulators Push Back

The tension between state insurance regulators and Medicare Advantage (MA) carriers is reaching a new level. As insurers continue tightening their budgets and limiting new enrollment; often by cutting commissions to brokers and restricting access to online applications. Some state officials are challenging what they view as unfair and potentially unlawful practices when it comes to Medicare advantage compensation loss.

With the 2026 Medicare Annual Enrollment Period (AEP) already underway, this conflict could shape the future of how MA plans are marketed, sold, and regulated.

Why Carriers Are Reducing Broker Compensation

Financial pressures have been building within Medicare Advantage for several years. Rising utilization costs, increased regulatory scrutiny, and shrinking federal reimbursement have pushed Medicare insurers to prioritize profit stability over rapid membership growth.

As part of this shift, some carriers have:

• Eliminated or reduced commissions on specific plans
• Limited access to agent-facing online enrollment platforms
• Discouraged new enrollments that could attract higher-cost members

The carriers intend to use these measures to control risk and protect margins. Although for brokers and agents, the fallout is immediate; lost income, lowered client expectations, and fewer ways to serve Medicare beneficiaries effectively.

Watch a YouTube video on SEPs for discontinued Medicare advantage plans

States Begin to Challenge Commission Cuts

Insurance commissioners in Delaware, Idaho, Montana, Oklahoma, New Hampshire, and North Dakota have taken a firm stance: cutting or withholding commissions to reduce Medicare Advantage enrollment crosses the line into unfair trade practices.

Some regulators have directly warned carriers to stop using marketing tactics that restrict enrollment or disadvantage third-party marketers. Others have gone further:

• Idaho issued cease-and-desist orders against UnitedHealthcare and PacificSource for allegedly violating state insurance standards.
• Additional states have threatened penalties, sanctions, or legal action if insurers refuse to restore fair broker compensation.

State officials argue that if MA plans are sold within their borders, insurers must comply with state marketing and sales laws regardless of the program’s federal oversight.

The Stakes Are High for Both Sides

This conflict puts both insurers and brokers; and ultimately beneficiaries, in a difficult position.

For insurers, compliance with state demands could trigger:

• Tighter pricing
• Fewer $0 premium plans
• Potential consideration of market exits

As one industry expert noted, when carriers feel they cannot adjust compensation or enrollment strategy to manage risk, they may be more likely to scale back or leave smaller markets.

However, carriers also have strong incentives not to leave states completely. If an insurer exits a Medicare Advantage market, it is barred from re-entering for years. This could present a long-term setback few companies want to face.

For brokers, reduced compensation means:

• Inconsistent or unpredictable payment
• Competing against carriers that restrict access to enrollment platforms
• Difficulty supporting clients when carriers remove commissions after applications are already submitted

Marketing groups emphasized that commissions are built into plan pricing and actuarial calculations. In other words; carriers planned for these costs long before selling the product.

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Legal and Regulatory Questions

A key unresolved issue is whether state regulators have the authority to intervene in the sales and marketing of a federal healthcare program like Medicare Advantage.

Many legal experts believe states have more power than carriers acknowledge. They regulate:

• Agent licensing
• Marketing conduct
• Fair business practices within state borders

Some policy analysts argue that states may actually hold more leverage than CMS in enforcing sales and marketing standards; especially when unfair business practices affect consumers or licensed agents.

Idaho’s insurance director has signaled that the state expects legal challenges and is prepared to defend its position. This includes efforts to force insurers to retroactively pay withheld commissions.

On the other hand, insurers may counter-sue states, arguing that Medicare’s federal structure preempts state authority.

Where This Leaves Brokers and Beneficiaries

As this dispute unfolds, brokers remain stuck in the middle. They must comply with evolving state rules while navigating restrictive carrier policies. At the same time, beneficiaries risk losing access to the knowledgeable agents they rely on to explain coverage options, especially in rural or underserved markets.

Let’s Sum it all up

• Medicare Advantage carriers are reducing or eliminating broker commissions to limit new enrollment and protect margins.
• Insurance regulators in at least six states are challenging these tactics and threatening enforcement actions.
• If insurers restore full commissions, they risk enrolling higher-cost or unprofitable members, creating financial strain.
• The question of whether states can regulate MA sales and marketing remains unresolved, setting up likely court battles.

Stay updated on agent webinars and events.

Weight Loss Drugs and Medicare

If you are a Medicare agent, there is no doubt you have been asked about weight loss drugs and Medicare coverage. There is some big news for Medicare beneficiaries: starting in 2026, weight loss medications will be covered through a Medicare Part D pilot program. Thanks to recent deals between the Trump administration and drug makers Eli Lilly and Novo Nordisk, eligible clients can access these medications for just $50 per month, down from $1,000 or more.

Who Qualifies

Not everyone will be eligible. The program targets about 10% of Medicare enrollees with severe obesity or high-risk conditions:

• Severely obese (BMI > 35)
• Overweight (BMI > 27) with prediabetes or cardiovascular disease
• Obese with advanced kidney disease, heart failure, or uncontrolled hypertension

Medicare will cover about $245 per month, making the program affordable and accessible.

Watch a quick YouTube video to learn more about the Canadian Medstore

How We Got Here

Initially, in April 2025, CMS decided not to cover anti-obesity medications due to high costs. Estimates suggested a potential $25–35 billion increase in spending over the next decade.

Everything changed in November 2025 when the Trump administration negotiated directly with manufacturers as part of the “Most Favored Nation” initiative. The result: a dramatic price drop that made coverage feasible without straining the Medicare budget.

TrumpRx: Option for Everyone

Even those who don’t qualify for Medicare coverage will have access to lower-cost medications starting January 2026 through TrumpRx.gov.

• Starting price: between $350 and $245/month
• Oral GLP-1 options expected pending FDA approval
• Available to anyone, regardless of insurance

What Medicare Covers Now

Before 2026, Medicare Part B covers obesity screenings and behavioral therapy, while Part D may cover GLP-1 drugs only if prescribed for diabetes or other approved conditions. Weight loss drugs are not otherwise covered.

Why This Matters for Agents

This is a game-changing opportunity for clients managing obesity or related health conditions. Agents can:

• Check Part D formularies for covered weight loss medications
• Compare plans for eligible clients
• Track policy updates in real time

The new coverage replaces compounded semaglutide options, giving clients access to brand-name medications at lower costs.

Agents who want to stay updated on events and information, click here

Two Pricing Tracks

• Trump Deal (2026): $245/month to Medicare, $50 copay for eligible beneficiaries
• IRA Negotiations, put in place by the Biden administration, (2027): Could bring additional savings for Ozempic and Wegovy

Agents, join the team at Crowe – click here for online contracting

What seemed improbable months ago is now reality. By staying informed and guiding clients through their coverage options, agents provide real value during the 2026 enrollment season and beyond.